Elizabethton, TN

Hermitage Health Center

5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1633 Hillview Drive, Elizabethton, TN

(423) 543-2571

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

70

Certified beds

Average residents

53

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Twin Rivers Health & Rehabilitation

Operator or chain grouping

Approved since

2004-03-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

11 facilities

Chain averages 4 overall / 4 health / 3 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

0.92

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.32

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

4.18

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.85

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.75

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.61

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

3.44

CMS adjusted total nurse staffing hours

Case-mix index

1.66

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

28%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,324

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

Performance score

27.12

Composite VBP score used to determine payment impact.

Payment multiplier

0.9844

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.89

Performance 20.09% · Measure score 2.89 · Achievement 2.89 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

0

Performance 8.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

7.96

Baseline 34.43% · Performance 31.15% · Measure score 7.96 · Achievement 7.96 · Improvement 2.92

Adjusted total nurse staffing

0

Baseline 3.74 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.11%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 7.79%
Discharge to community	38.61%	50.57% 12 pts worse	No Different than the National Rate · Eligible stays 50 · Observed rate 30% · Lower 95% interval 31.52%
Medicare spending per beneficiary	1.28	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 44 · Denominator 44
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 44
Discharge self-care score	31.43%	53.69% 22.3 pts worse	Numerator 11 · Denominator 35
Discharge mobility score	31.43%	50.94% 19.5 pts worse	Numerator 11 · Denominator 35
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 44 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.5%	7.12% 1.4 pts worse	No Different than the National Rate · Eligible stays 44 · Observed rate 13.64% · Lower 95% interval 4.58%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 77
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	40%	56.45% 16.5 pts worse	Numerator 14 · Denominator 35
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 27

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.6 0.2 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.3	1.6 1.3 pts better	1.8 1.5 pts better	Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.9% 10.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	4.3%	3.6% 0.7 pts worse	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.4% · Q3 2.2% · Q4 2.0% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	88.6%	11.8% 76.8 pts worse	11.4% 77.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 77.3% · Q4 79.6% · 4Q avg 88.6%
Percentage of long-stay residents who lose too much weight	0.7%	6.2% 5.5 pts better	5.4% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7%
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 29.7% · Q2 34.2% · Q3 36.8% · Q4 46.3% · 4Q avg 37.0%
Percentage of long-stay residents who received an antipsychotic medication	13.3%	18.1% 4.8 pts better	16.7% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 10.3% · Q3 10.0% · Q4 15.6% · 4Q avg 13.3% · 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	14.2%	19.9% 5.7 pts better	16.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q4 16.8% · 4Q avg 14.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.4%	15.3% 1.1 pts worse	14.9% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 22.9% · Q3 8.8% · Q4 15.8% · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.3%	0.9% 1.4 pts worse	1.0% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 4.5% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.9%	1.9% 2 pts worse	1.7% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.0% · Q3 4.5% · Q4 4.1% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.7%	20.2% 4.5 pts worse	19.8% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 27.5% · Q3 18.2% · Q4 29.6% · 4Q avg 24.7%
Percentage of long-stay residents with pressure ulcers	2.3%	5.4% 3.1 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 1.8% · Q4 3.2% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	79.6% 20.4 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	12.4%	11.2% 1.2 pts worse	12.0% 0.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 10.0% · Expected 9.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.6% 0.6 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.6% · Q3 0.0% · Q4 4.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	79.8% 20.2 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	12.6%	22.2% 9.6 pts better	23.9% 11.3 pts better	Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 10.0% · Expected 18.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-20 · Fire 2025-05-20

2 health deficiencies

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

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2022-08-10 · Fire 2022-08-10

2 health deficiencies

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

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-11-06 · Fire 2019-11-06

1 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-05-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-27

D · Potential for more than minimal harm 2025-05-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-05-19

D · Potential for more than minimal harm 2024-01-10

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2024-02-02

F · Potential for more than minimal harm 2022-08-10

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2022-09-15

D · Potential for more than minimal harm 2022-08-10

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-08-08

D · Potential for more than minimal harm 2019-11-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-11-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-05-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-05-30

D · Potential for more than minimal harm 2025-05-20

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-05-31

D · Potential for more than minimal harm 2022-08-10

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 2022-09-15

D · Potential for more than minimal harm 2022-08-10

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-09-15

D · Potential for more than minimal harm 2019-11-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-11-08

Penalties and ownership