Cycle 1
Health 2025-12-03 · Fire 2025-12-03
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jonesborough, TN
Four Oaks Health Care Center
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1101 Persimmon Ridge Rd, Jonesborough, TN
(423) 753-8711
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
2002-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,054
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.62
Baseline 7.34% · Performance 7.05% · Measure score 2.62 · Achievement 2.62 · Improvement 0.73
Total nurse turnover
0
Baseline 62.69% · Performance 80.60% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.88 hours · Performance 2.90 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 6.86% |
| Discharge to community | 47.52% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 46.43% · Lower 95% interval 34.34% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 42.42% |
53.69%
11.3 pts worse
|
Numerator 14 · Denominator 33 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 15 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 15.49% |
42%
26.5 pts worse
|
Numerator 11 · Denominator 71 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8% |
25.2%
17.2 pts worse
|
Numerator 2 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.7 · Observed 3.1 · Expected 3.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.5 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
89.9%
5.9 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 93.3% · Q3 100.0% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.5%
2.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 3.4% · Q4 3.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
11.8%
9.1 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 1.8% · Q3 1.8% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.2%
1.8 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 8.7% · Q3 7.7% · Q4 7.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.0% |
32.2%
4.8 pts worse
|
19.6%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.4% · Q2 37.5% · Q3 34.1% · Q4 31.0% · 4Q avg 37.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
18.1%
4.7 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 11.8% · Q3 13.8% · Q4 12.1% · 4Q avg 13.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.6% |
19.9%
12.3 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
15.3%
5.3 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.8% · Q3 7.3% · Q4 9.5% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
1.9%
3.3 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.4% · Q3 12.7% · Q4 0.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
20.2%
4.8 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 12.8% · Q3 10.6% · Q4 21.2% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.4%
0.1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 5.0% · Q4 1.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
79.6%
4.8 pts better
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 67.1% · Q2 82.4% · Q3 94.3% · Q4 98.1% · 4Q avg 84.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.2%
2.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.6%
0.8 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.7% |
79.8%
1.9 pts better
|
79.7%
2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
22.2%
3.2 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 25.0% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-23 · Fire 2023-02-23
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-10-02 · Fire 2019-10-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-30
D · Potential for more than minimal harm
2024-06-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-28
F · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-03-16
F · Potential for more than minimal harm
2019-10-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-11-08
D · Potential for more than minimal harm
2019-10-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-12-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-03-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-07
D · Potential for more than minimal harm
2023-09-08
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-14
D · Potential for more than minimal harm
2023-02-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-23
F657 · Resident Assessment and Care Planning Deficiencies
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 2023-03-16
D · Potential for more than minimal harm
2023-02-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
Ownership
Mfi Healthcare Tn Ii LLC
5% Or Greater Direct Ownership Interest · Organization
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Niederman, Anshel
5% Or Greater Indirect Ownership Interest · Individual
Mce Associates LLC
5% Or Greater Indirect Ownership Interest · Organization
Neuman, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Labin, Shiya
5% Or Greater Indirect Ownership Interest · Individual
Edwards, Tammy
Operational/Managerial Control · Individual
Niederman, Anshel
Corporate Officer · Individual
Rosenhein, Brian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Lakebridge, A Waters Community, LLC
Johnson City, TN
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Waters Of Johnson City, LLC
Johnson City, TN
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Agape Rehabilitation & Nursing Center, A Waters Cm
Johnson City, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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