Cycle 1
Health 2024-10-23 · Fire 2024-10-23
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Dayton, TN
Laurelbrook Nursing Home
1-star overall rating with 1-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
200 Sanitarium Circle, Dayton, TN
(423) 775-0771
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2019-09-19
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
0.79
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
17%
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
2,280
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0047
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.01
Baseline 68.75% · Performance 48.94% · Measure score 4.01 · Achievement 3.61 · Improvement 4.01
Adjusted total nurse staffing
6.09
Baseline 3.67 hours · Performance 4.81 hours · Measure score 6.09 · Achievement 6.09 · Improvement 4.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 9.71% |
8.2%
1.5 pts better
|
Numerator 10 · Denominator 103 |
| Staff flu vaccination coverage | 30.49% |
42%
11.5 pts worse
|
Numerator 25 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.6
1.1 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
89.9%
6.7 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 95.6% · Q3 97.7% · Q4 98.0% · 4Q avg 96.6% |
| 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 | 1.7% |
3.6%
1.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 4.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
11.8%
9.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 2.7% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 18.3% |
6.2%
12.1 pts worse
|
5.4%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.9% · Q3 22.6% · Q4 25.8% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 51.6% |
32.2%
19.4 pts worse
|
19.6%
32 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 48.4% · Q3 59.4% · Q4 54.8% · 4Q avg 51.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.2% |
18.1%
17.1 pts worse
|
16.7%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 30.4% · Q3 34.8% · Q4 43.5% · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.7% |
0.1%
1.6 pts worse
|
0.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.2% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.3% |
19.9%
8.4 pts worse
|
16.3%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
15.3%
2.8 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 15.0% · Q3 4.5% · Q4 20.0% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.9%
2.7 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.1% · Q3 1.6% · Q4 1.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.9%
0.4 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.2% · Q3 0.0% · Q4 4.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.9% |
20.2%
14.3 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 7.5% · Q3 4.7% · Q4 2.1% · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.4%
About the same
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 9.2% · Q3 2.1% · Q4 4.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.5% |
79.6%
1.9 pts better
|
81.7%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · 4Q avg 81.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
79.8%
29.8 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-18 · Fire 2022-02-18
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-08-20 · Fire 2019-08-20
6 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-10-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-10-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-10-25
F · Potential for more than minimal harm
2022-02-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-18
D · Potential for more than minimal harm
2019-08-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-23
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 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-15
D · Potential for more than minimal harm
2024-10-23
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 2024-11-15
D · Potential for more than minimal harm
2023-12-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-13
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 2024-01-23
D · Potential for more than minimal harm
2023-12-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
J · Immediate jeopardy
2022-02-18
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-03-17
J · Immediate jeopardy
2022-02-18
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 2022-03-17
J · Immediate jeopardy
2022-02-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-17
J · Immediate jeopardy
2022-02-18
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-03-17
J · Immediate jeopardy
2022-02-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-17
D · Potential for more than minimal harm
2019-08-20
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-09-23
D · Potential for more than minimal harm
2019-08-20
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 2019-09-23
D · Potential for more than minimal harm
2019-08-20
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 2019-09-23
Penalties and ownership
What sits behind the stars
Ownership
Mcdaniels, Warren
Corporate Officer · Individual
Sutton, Rich
Corporate Officer · Individual
Svendsen, Torben
Operational/Managerial Control · Individual
Traxler, Brian
Operational/Managerial Control · Individual
Traxler, Brian
Corporate Director · Individual
Wellman, Keith
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Rhea County
Dayton, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bledsoe County Nursing Home
Pikeville, TN
0-star overall rating with 0-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Sequatchie
Dunlap, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies
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