2 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Dover, TN
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
537 Spring Street Suite 350, Dover, TN
(931) 232-6902
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
88
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Exceptional Living Centers
Operator or chain grouping
Approved since
1983-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.88
Registered nurse staffing
LPN hours / resident day
0.50
Licensed practical nurse staffing
Aide hours / resident day
2.12
Nurse aide staffing
Weekend hours
2.93
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.6
1.2 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
89.9%
7.9 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 65.4% |
94.5%
29.1 pts worse
|
95.5%
30.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.6%
0.9 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
11.8%
7.5 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.2%
0.4 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.1% |
32.2%
0.9 pts worse
|
19.6%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
18.1%
2.1 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.9% |
19.9%
6 pts better
|
16.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
15.3%
7.5 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.9%
0.8 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.0% |
20.2%
0.2 pts better
|
19.8%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.4%
2.5 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
79.6%
15.2 pts better
|
81.7%
13.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
11.2%
7.3 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.6%
2.2 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.6% |
79.8%
19.2 pts worse
|
79.7%
19.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.6% |
22.2%
8.6 pts better
|
23.9%
10.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-08-29
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-31
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-14
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-26
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-08-25
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-07
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-08
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-08
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-08
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-11-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-10-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-14
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-10-14
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-14
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-10-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-10-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-09-16
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-16
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
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