Crossville, TN

Good Samaritan Society - Fairfield Glade

5-star overall rating with 3-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

100 Samaritan Way, Crossville, TN

(931) 456-1576

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

53

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Good Samaritan Society

Operator or chain grouping

Approved since

2011-10-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

89 facilities

Chain averages 3 overall / 3 health / 4 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

1.04

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

0.95

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.20

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

4.19

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.99

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.53

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.51

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

1.16

CMS adjusted RN staffing hours

Adjusted total hours

4.70

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

18%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,201

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.05

Composite VBP score used to determine payment impact.

Payment multiplier

0.9903

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.52

Baseline 17.89% · Performance 18.41% · Measure score 6.52 · Achievement 6.52 · Improvement 0

Healthcare-associated infections

4.25

Baseline 6.05% · Performance 6.57% · Measure score 4.25 · Achievement 4.25 · Improvement 0

Total nurse turnover

0

Baseline 52.05% · Performance 71.64% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

4.05

Baseline 4.95 hours · Performance 4.23 hours · Measure score 4.05 · Achievement 4.05 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.3%
10.72%
1.4 pts better
No Different than the National Rate · Eligible stays 207 · Observed rate 6.28% · Lower 95% interval 7.11%
Discharge to community 59.53%
50.57%
9 pts better
Better than the National Rate · Eligible stays 213 · Observed rate 58.69% · Lower 95% interval 54.77%
Medicare spending per beneficiary 0.85
1.02
0.2 pts better
Drug regimen review with follow-up 99.12%
95.27%
3.9 pts better
Numerator 113 · Denominator 114
Falls with major injury 0.88%
0.77%
0.1 pts worse
Numerator 1 · Denominator 114
Discharge self-care score 63.27%
53.69%
9.6 pts better
Numerator 62 · Denominator 98
Discharge mobility score 62.24%
50.94%
11.3 pts better
Numerator 61 · Denominator 98
Pressure ulcers or injuries, new or worsened 0.88%
2.29%
1.4 pts better
Numerator 1 · Denominator 114 · Adjusted rate 0.92%
Healthcare-associated infections requiring hospitalization 6.57%
7.12%
0.5 pts better
No Different than the National Rate · Eligible stays 128 · Observed rate 4.69% · Lower 95% interval 4.36%
Staff COVID-19 vaccination coverage 1.02%
8.2%
7.2 pts worse
Numerator 1 · Denominator 98
Staff flu vaccination coverage 63.64%
42%
21.6 pts better
Numerator 91 · Denominator 143
Discharge function score 68.37%
56.45%
11.9 pts better
Numerator 67 · Denominator 98
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 59 · Denominator 59
Transfer of health information to patient 97.92%
96.28%
1.6 pts better
Numerator 47 · Denominator 48
Resident COVID-19 vaccinations up to date 35.82%
25.2%
10.6 pts better
Numerator 24 · Denominator 67

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.6
1.6
1 pts better
1.9
1.3 pts better
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.9
1.6
0.7 pts better
1.8
0.9 pts better
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.1%
89.9%
9.2 pts better
93.4%
5.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94.6%
94.5%
0.1 pts better
95.5%
0.9 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6%
Percentage of long-stay residents experiencing one or more falls with major injury 7.8%
3.6%
4.2 pts worse
3.3%
4.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.1% · Q3 7.4% · Q4 7.7% · 4Q avg 7.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.0%
11.8%
11.8 pts better
11.4%
11.4 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 who lose too much weight 4.0%
6.2%
2.2 pts better
5.4%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.6% · Q3 0.0% · Q4 4.5% · 4Q avg 4.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.0%
32.2%
18.2 pts better
19.6%
5.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 19.4% · Q3 12.0% · Q4 4.2% · 4Q avg 14.0%
Percentage of long-stay residents who received an antipsychotic medication 13.0%
18.1%
5.1 pts better
16.7%
3.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 15.0% · 4Q avg 13.0% · 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 30.5%
19.9%
10.6 pts worse
16.3%
14.2 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 12.0%
15.3%
3.3 pts better
14.9%
2.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 25.0% · Q4 17.4% · 4Q avg 12.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.9%
0.9 pts better
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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
1.9%
1.9 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 19.3%
20.2%
0.9 pts better
19.8%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 16.3% · Q3 23.0% · Q4 21.3% · 4Q avg 19.3%
Percentage of long-stay residents with pressure ulcers 4.2%
5.4%
1.2 pts better
5.1%
0.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.8% · Q3 0.0% · Q4 6.1% · 4Q avg 4.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.6%
79.6%
20 pts better
81.7%
17.9 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.6%
Percentage of short-stay residents who had an outpatient emergency department visit 7.6%
11.2%
3.6 pts better
12.0%
4.4 pts better
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.4% · Expected 9.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.0%
1.6%
0.6 pts better
1.6%
0.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92.4%
79.8%
12.6 pts better
79.7%
12.7 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 17.8%
22.2%
4.4 pts better
23.9%
6.1 pts better
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 13.6% · Expected 18.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-05-03 · Fire 2023-05-03

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2019-11-14 · Fire 2019-11-14

3 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2018-10-03 · Fire 2018-10-03

7 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-05-03

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-15

F · Potential for more than minimal harm 2023-05-03

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2023-06-15

E · Potential for more than minimal harm 2023-05-03

K222 · Egress Deficiencies

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 2023-06-15

D · Potential for more than minimal harm 2023-05-03

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-05-03

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-06-15

D · Potential for more than minimal harm 2023-05-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-15

D · Potential for more than minimal harm 2019-11-14

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2019-12-29

D · Potential for more than minimal harm 2019-11-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-29

D · Potential for more than minimal harm 2018-10-03

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2018-11-07

D · Potential for more than minimal harm 2018-10-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-10-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-10-07

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-18

E · Potential for more than minimal harm 2023-05-03

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-05-03

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 2023-06-06

D · Potential for more than minimal harm 2023-05-03

F761 · Pharmacy Service Deficiencies

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 2023-06-06

D · Potential for more than minimal harm 2023-04-06

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 2023-05-10

D · Potential for more than minimal harm 2023-04-06

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-05-10

D · Potential for more than minimal harm 2019-11-14

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2019-12-02

C · Minimal harm 2019-11-14

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 2019-12-02

F · Potential for more than minimal harm 2018-10-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-11-01

D · Potential for more than minimal harm 2018-10-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-10-16

D · Potential for more than minimal harm 2018-10-03

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2018-11-05

D · Potential for more than minimal harm 2018-10-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2018-11-01

D · Potential for more than minimal harm 2018-10-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-11-05

Penalties and ownership

What sits behind the stars

Ownership

Sanford

5% Or Greater Direct Ownership Interest · Organization

100% 89 facilities 2019-01-01
Brown, George

Corporate Director · Individual

0% 64 facilities 2025-01-01
Cotton, Barry

Operational/Managerial Control · Individual

0% 1 facilities 2023-07-17
Dykhouse, Dana

Corporate Director · Individual

0% 85 facilities 2024-05-30
Engbrecht, Wesley

Corporate Director · Individual

0% 89 facilities 2024-05-30
Fluit, Joel

Corporate Officer · Individual

0% 88 facilities 2022-10-01
Gassen, William

Corporate Director · Individual

0% 89 facilities 2024-05-30
Gassen, William

Corporate Officer · Individual

0% 89 facilities 2024-05-30
Gulsvig, Neil

Corporate Director · Individual

0% 89 facilities 2024-05-30
Herseth Sandlin, Stephanie

Corporate Director · Individual

0% 86 facilities 2024-05-30
Lundeen, Mark

Corporate Director · Individual

0% 89 facilities 2024-05-30
Mccausland, Maureen

Corporate Director · Individual

0% 61 facilities 2025-01-01
Middleton, Aimee

Corporate Officer · Individual

0% 88 facilities 2022-01-27
Molbert, Lauris

Corporate Director · Individual

0% 89 facilities 2024-05-30
Morrison, Tony

Operational/Managerial Control · Individual

0% 89 facilities 2019-01-01
North, Andrew

Corporate Director · Individual

0% 89 facilities 2024-05-30
Olson, Nicholas

Corporate Officer · Individual

0% 87 facilities 2024-04-08
Petty, Elizabeth

Operational/Managerial Control · Individual

0% 1 facilities 2018-09-01
Schema, Nathan

Corporate Officer · Individual

0% 88 facilities 2022-01-01
Schieffer, Kevin

Corporate Director · Individual

0% 61 facilities 2025-01-01
Shulkin, David

Corporate Officer · Individual

0% 85 facilities 2024-05-30
Teiken, Brent

Corporate Director · Individual

0% 89 facilities 2024-05-30
The Evangelical Lutheran Good Samaritan Society

Operational/Managerial Control · Organization

0% 88 facilities 2019-01-01
Ventling-Herrmann, Marnie

Corporate Director · Individual

0% 89 facilities 2024-05-30
Wenzel, Thomas

Corporate Director · Individual

0% 61 facilities 2025-01-01

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Staffing
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Overall
3 / 5
Health
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Staffing
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Fines
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Staffing
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