Cycle 1
Health 2025-01-23 · Fire 2025-01-23
4 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Savannah, TN
Hardin County Nh
1-star overall rating with 1-star inspections with $67,490 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
935 Wayne Road, Savannah, TN
(731) 925-4954
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
36
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.61
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.25
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
0.48
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,065
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.76% · Performance 22.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.06
Baseline 8.18% · Performance 7.68% · Measure score 1.06 · Achievement 0.51 · Improvement 1.06
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.40
Baseline 4.59 hours · Performance 4.61 hours · Measure score 5.40 · Achievement 5.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.93% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 11.51% · Lower 95% interval 9.08% |
| Discharge to community | 50.41% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 49.35% · Lower 95% interval 41.74% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 94 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 30 · Denominator 60 |
| Discharge mobility score | 48.33% |
50.94%
2.6 pts worse
|
Numerator 29 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.06% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 94 · Adjusted rate 1.22% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 6.59% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 5.17% |
8.2%
3 pts worse
|
Numerator 3 · Denominator 58 |
| Staff flu vaccination coverage | 72.09% |
42%
30.1 pts better
|
Numerator 31 · Denominator 43 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 22 · Denominator 60 |
| Transfer of health information to provider | 98.31% |
95.95%
2.4 pts better
|
Numerator 58 · Denominator 59 |
| 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 | 13.46% |
25.2%
11.7 pts worse
|
Numerator 7 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
89.9%
8.2 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 96.6% · Q3 100.0% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.3% |
3.6%
5.7 pts worse
|
3.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.3% · Q3 11.5% · Q4 4.2% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
11.8%
3.7 pts better
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 17.6% |
6.2%
11.4 pts worse
|
5.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.0% · Q3 9.5% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.8% |
32.2%
15.6 pts worse
|
19.6%
28.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 50.0% · Q3 42.9% · 4Q avg 47.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
18.1%
0.7 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · 4Q avg 18.8% · 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 | 24.0% |
19.9%
4.1 pts worse
|
16.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
15.3%
10.6 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 31.8% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.9% |
1.9%
4 pts worse
|
1.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 11.5% · Q4 4.2% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.0% |
20.2%
17.2 pts better
|
19.8%
16.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.8% · Q3 3.7% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.4%
2.1 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 10.0% · Q4 14.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
79.6%
8.6 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.9% · Q2 86.6% · Q3 88.5% · Q4 91.7% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.2%
0.4 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 12.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.6%
0.7 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.4% · Q3 2.7% · Q4 2.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
79.8%
13.1 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.2%
4.2 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 18.1% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
5 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-03-28 · Fire 2022-03-28
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-12
F · Potential for more than minimal harm
2024-02-14
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 2024-03-15
D · Potential for more than minimal harm
2024-02-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-15
Inspection history
Recent health citations
G · Actual harm
2025-01-23
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 2025-02-10
F · Potential for more than minimal harm
2025-01-23
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-23
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 2025-02-10
D · Potential for more than minimal harm
2025-01-23
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 2025-02-10
J · Immediate jeopardy
2024-02-14
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 2024-04-10
J · Immediate jeopardy
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-09
D · Potential for more than minimal harm
2024-02-14
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 2024-04-09
D · Potential for more than minimal harm
2024-02-14
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 2024-04-10
D · Potential for more than minimal harm
2024-02-14
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 2024-04-09
J · Immediate jeopardy
2022-03-28
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 2022-04-26
J · Immediate jeopardy
2022-03-28
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 2022-04-26
J · Immediate jeopardy
2022-03-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-04-26
J · Immediate jeopardy
2022-03-28
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 2022-04-26
J · Immediate jeopardy
2022-03-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-04-26
J · Immediate jeopardy
2022-03-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-04-26
F · Potential for more than minimal harm
2022-03-28
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 2022-04-26
F · Potential for more than minimal harm
2022-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-26
E · Potential for more than minimal harm
2022-03-28
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 2022-04-26
D · Potential for more than minimal harm
2022-03-28
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 2022-04-26
D · Potential for more than minimal harm
2022-03-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-28
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-04-26
D · Potential for more than minimal harm
2022-03-28
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 2022-04-26
Penalties and ownership
What sits behind the stars
$14,505
2025-01-23
Fine
Fine · fine $14,505
Fine
$52,985
2024-02-14
Fine
Fine · fine $52,985
Fine
$0
2024-02-14
Payment Denial
Payment Denial · denial start 2024-02-18 · 52 days
52 day denial
Ownership
Hardin County General Hospital
5% Or Greater Direct Ownership Interest · Organization
Edmondson, James
Corporate Officer · Individual
Edmondson, James
W-2 Managing Employee · Individual
Hughes, Leigh Ann
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Hardin Home
Savannah, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Park Rest Hardin County Health Center
Savannah, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Savannah Nursing And Rehabilitation
Savannah, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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