Cycle 1
Health 2022-08-17 · Fire 2022-08-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Dandridge, TN
Jefferson County Nursing Home
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
914 Industrial Park Rd, Dandridge, TN
(865) 397-3163
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
145
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-01-22
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
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
871
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0176
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.79
Baseline 23.12% · Performance 19.29% · Measure score 5.79 · Achievement 4.62 · Improvement 5.79
Healthcare-associated infections
7.37
Baseline 6.48% · Performance 5.63% · Measure score 7.37 · Achievement 7.37 · Improvement 5.21
Total nurse turnover
6.63
Baseline 40.12% · Performance 36.59% · Measure score 6.63 · Achievement 6.63 · Improvement 1.81
Adjusted total nurse staffing
5.30
Baseline 4.44 hours · Performance 4.59 hours · Measure score 5.30 · Achievement 5.30 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 10.05% · Lower 95% interval 8.11% |
| Discharge to community | 46.48% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 42.01% · Lower 95% interval 38.95% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 88 · Denominator 90 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 90 |
| Discharge self-care score | 30.67% |
53.69%
23 pts worse
|
Numerator 23 · Denominator 75 |
| Discharge mobility score | 24% |
50.94%
26.9 pts worse
|
Numerator 18 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 3 · Denominator 90 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 5.63% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 2.78% · Lower 95% interval 2.94% |
| Staff COVID-19 vaccination coverage | 0.36% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 274 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.67% |
56.45%
21.8 pts worse
|
Numerator 26 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 7.5% |
25.2%
17.7 pts worse
|
Numerator 3 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.9%
9.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
94.5%
2.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.6%
1.9 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.1% · Q3 3.9% · Q4 3.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
11.8%
11.6 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.2%
0.8 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.1% · Q3 2.0% · Q4 8.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.4% |
32.2%
3.2 pts worse
|
19.6%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 37.6% · Q3 36.5% · Q4 39.6% · 4Q avg 35.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
18.1%
5.7 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 11.8% · Q3 15.3% · Q4 16.5% · 4Q avg 12.4% · 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 | 37.6% |
19.9%
17.7 pts worse
|
16.3%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q3 49.6% · Q4 33.2% · 4Q avg 37.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.1% |
15.3%
13.8 pts worse
|
14.9%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 20.6% · Q3 30.3% · Q4 32.7% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.9%
1.5 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
20.2%
6 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 26.8% · Q3 28.5% · Q4 23.2% · 4Q avg 26.2% |
| 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 · Q1 2.2% · Q2 2.2% · Q3 3.0% · Q4 4.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
79.6%
15.3 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 92.0% · Q3 98.4% · Q4 97.5% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
11.2%
0.4 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.5% |
79.8%
0.7 pts better
|
79.7%
0.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
22.2%
1.3 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 21.7% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-18 · Fire 2019-09-18
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-09-19 · Fire 2018-09-19
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
F · Potential for more than minimal harm
2022-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-09-30
E · Potential for more than minimal harm
2022-08-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-30
F · Potential for more than minimal harm
2019-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-25
F · Potential for more than minimal harm
2019-09-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-09-18
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 2019-10-25
D · Potential for more than minimal harm
2019-09-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-25
F · Potential for more than minimal harm
2018-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-02
F · Potential for more than minimal harm
2018-09-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-11-02
E · Potential for more than minimal harm
2018-09-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-11-02
E · Potential for more than minimal harm
2018-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-11-02
D · Potential for more than minimal harm
2018-09-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2018-11-02
C · Minimal harm
2018-09-19
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-11-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-08-17
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 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-09-30
F · Potential for more than minimal harm
2019-09-18
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 2019-10-25
E · Potential for more than minimal harm
2018-09-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-11-02
D · Potential for more than minimal harm
2018-09-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-11-02
Penalties and ownership
What sits behind the stars
Ownership
Jefferson County Government
5% Or Greater Direct Ownership Interest · Organization
Mynatt, Roger
Operational/Managerial Control · Individual
Potts, Mark
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Jefferson City Health And Rehab Center
Jefferson City, TN
2-star overall rating with 2-star inspections with $8,788 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Jefferson City
Jefferson City, TN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Jefferson Park At White Pine
White Pine, TN
0-star overall rating with 0-star inspections
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