Cycle 1
Health 2022-08-17 · Fire 2022-08-17
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lebanon, TN
Lebanon Center For Rehabilitation And Healing, LLC
5-star overall rating with 4-star inspections with 1 recent health deficiencies
731 Castle Heights Court, Lebanon, TN
(615) 444-4319
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1991-05-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.65
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0016
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.82
Baseline 19.11% · Performance 17.81% · Measure score 7.82 · Achievement 7.82 · Improvement 5.76
Healthcare-associated infections
6.97
Baseline 8.72% · Performance 5.94% · Measure score 6.97 · Achievement 6.34 · Improvement 6.97
Total nurse turnover
4.39
Baseline 74.03% · Performance 50.00% · Measure score 4.39 · Achievement 3.35 · Improvement 4.39
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 2.83 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 8.95% · Lower 95% interval 6.84% |
| Discharge to community | 65.32% |
50.57%
14.7 pts better
|
Better than the National Rate · Eligible stays 256 · Observed rate 61.72% · Lower 95% interval 59.08% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 209 · Denominator 209 |
| Falls with major injury | 0.48% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 209 |
| Discharge self-care score | 60.76% |
53.69%
7.1 pts better
|
Numerator 96 · Denominator 158 |
| Discharge mobility score | 43.04% |
50.94%
7.9 pts worse
|
Numerator 68 · Denominator 158 |
| Pressure ulcers or injuries, new or worsened | 1.91% |
2.29%
0.4 pts better
|
Numerator 4 · Denominator 209 · Adjusted rate 1.97% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 4.52% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 11.24% |
8.2%
3 pts better
|
Numerator 10 · Denominator 89 |
| Staff flu vaccination coverage | 29.35% |
42%
12.6 pts worse
|
Numerator 27 · Denominator 92 |
| Discharge function score | 73.42% |
56.45%
17 pts better
|
Numerator 116 · Denominator 158 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 109 · Denominator 109 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 82 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 25.21% |
25.2%
About the same
|
Numerator 30 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.9%
7.1 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 97.0% |
| 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 | 7.5% |
3.6%
3.9 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
11.8%
8.6 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
6.2%
0.2 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
32.2%
0.2 pts better
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
18.1%
12.5 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
15.3%
4.7 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
20.2%
2.6 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.4%
0.6 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
79.6%
16.4 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 97.5% · Q3 94.7% · Q4 95.9% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
11.2%
2.5 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.6%
1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
79.8%
18.4 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
22.2%
2.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 24.9% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-01 · Fire 2019-10-01
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-10-03 · Fire 2018-10-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-10-01
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-11-15
D · Potential for more than minimal harm
2018-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-10-02
D · Potential for more than minimal harm
2018-10-03
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-10-02
D · Potential for more than minimal harm
2018-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-10-03
D · Potential for more than minimal harm
2018-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-24
D · Potential for more than minimal harm
2018-10-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2018-10-07
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 2022-08-31
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 2018-11-02
D · Potential for more than minimal harm
2018-10-03
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2018-11-02
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 2018-11-02
Penalties and ownership
What sits behind the stars
Ownership
Md Friedman Family 2017 Trust
5% Or Greater Direct Ownership Interest · Organization
Neal Einhorn Family 2017 Trust
5% Or Greater Direct Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Direct Ownership Interest · Individual
Zucker, Yossie
5% Or Greater Direct Ownership Interest · Individual
Friedman, Mark
Corporate Officer · Individual
Hickman, Nioakah
Operational/Managerial Control · Individual
Lewis, Rebecca
Operational/Managerial Control · Individual
Sy, Bernard
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pavilion-Ths, LLC
Lebanon, TN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Quality Center For Rehabilitation And Healing LLC
Lebanon, TN
1-star overall rating with 2-star inspections with $21,206 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cedar Creek Post Acute
Mount Juliet, TN
1-star overall rating with 1-star inspections with $211,244 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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