Gainesboro, TN

Mabry Health Care

3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1340 N Grundy Quarles Hwy, Gainesboro, TN

(931) 268-0291

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

58

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1991-10-24

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

70 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 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

0.33

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.04

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.12

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.21

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

0.27

CMS adjusted RN staffing hours

Adjusted total hours

2.87

CMS adjusted total nurse staffing hours

Case-mix index

1.64

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,688

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

Performance score

1.70

Composite VBP score used to determine payment impact.

Payment multiplier

0.9804

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.51

Baseline 20.21% · Performance 21.20% · Measure score 0.51 · Achievement 0.51 · Improvement 0

Healthcare-associated infections

0

Baseline 6.78% · Performance 9.64% · Measure score 0 · Achievement 0 · Improvement 0

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

0

Baseline 3.65 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.42%	10.72% 1.7 pts worse	No Different than the National Rate · Eligible stays 89 · Observed rate 17.98% · Lower 95% interval 9.21%
Discharge to community	45.88%	50.57% 4.7 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 36.51% · Lower 95% interval 34.97%
Medicare spending per beneficiary	1.21	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 64 · Denominator 64
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 64
Discharge self-care score	37.84%	53.69% 15.8 pts worse	Numerator 14 · Denominator 37
Discharge mobility score	29.73%	50.94% 21.2 pts worse	Numerator 11 · Denominator 37
Pressure ulcers or injuries, new or worsened	1.56%	2.29% 0.7 pts better	Numerator 1 · Denominator 64 · Adjusted rate 1.27%
Healthcare-associated infections requiring hospitalization	9.64%	7.12% 2.5 pts worse	No Different than the National Rate · Eligible stays 52 · Observed rate 17.31% · Lower 95% interval 6.13%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 49
Staff flu vaccination coverage	17.19%	42% 24.8 pts worse	Numerator 11 · Denominator 64
Discharge function score	48.65%	56.45% 7.8 pts worse	Numerator 18 · Denominator 37
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 32 · Denominator 32
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	36.84%	25.2% 11.6 pts better	Numerator 14 · Denominator 38

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.3	1.6 0.3 pts better	1.9 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.6 0.8 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.4%	89.9% 6.5 pts better	93.4% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.7% · Q3 97.6% · Q4 93.8% · 4Q avg 96.4%
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	8.4%	3.6% 4.8 pts worse	3.3% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 9.3% · Q3 7.3% · Q4 6.2% · 4Q avg 8.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	27.2%	11.8% 15.4 pts worse	11.4% 15.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 26.8% · Q3 17.9% · Q4 37.8% · 4Q avg 27.2%
Percentage of long-stay residents who lose too much weight	12.2%	6.2% 6 pts worse	5.4% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 19.4% · Q3 11.1% · Q4 6.8% · 4Q avg 12.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.3%	32.2% 6.9 pts better	19.6% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 21.6% · Q3 21.1% · Q4 25.0% · 4Q avg 25.3%
Percentage of long-stay residents who received an antipsychotic medication	18.9%	18.1% 0.8 pts worse	16.7% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q3 14.3% · Q4 22.6% · 4Q avg 18.9% · 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	14.5%	19.9% 5.4 pts better	16.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.2%	15.3% 3.1 pts better	14.9% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.9% · Q3 19.4% · Q4 14.6% · 4Q avg 12.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.9% 0.1 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.9% 0.7 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.8%	20.2% 4.6 pts worse	19.8% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 27.1% · Q3 21.9% · Q4 28.0% · 4Q avg 24.8%
Percentage of long-stay residents with pressure ulcers	4.0%	5.4% 1.4 pts better	5.1% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.8% · Q3 2.0% · Q4 2.5% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	87.6%	79.6% 8 pts better	81.7% 5.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 89.3% · Q3 92.2% · Q4 81.7% · 4Q avg 87.6%
Percentage of short-stay residents who had an outpatient emergency department visit	12.3%	11.2% 1.1 pts worse	12.0% 0.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 13.3% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.6% 1.6 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	78.9%	79.8% 0.9 pts worse	79.7% 0.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 78.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.8%	22.2% 3.6 pts worse	23.9% 1.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 28.3% · Expected 26.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-05 · Fire 2025-02-05

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2020-03-18 · Fire 2020-03-18

1 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

8 fire-safety deficiencies

Top issue: Emergency Preparedness (6 deficiencies)

Cycle 3 Health 2019-03-05 · Fire 2019-03-05

3 health deficiencies

Top issue: Infection Control (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-05

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 2025-02-04

D · Potential for more than minimal harm 2025-02-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-02-06

D · Potential for more than minimal harm 2020-03-18

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

E34 · Emergency Preparedness Deficiencies

Fire Safety

Provide a means of sharing information on occupancy/needs.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2020-03-30

D · Potential for more than minimal harm 2020-03-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-04-02

D · Potential for more than minimal harm 2020-03-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-04-02

D · Potential for more than minimal harm 2019-03-05

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2019-03-13

D · Potential for more than minimal harm 2019-03-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-03-18

D · Potential for more than minimal harm 2019-03-05

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-03-13

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-05

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-02-05

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 2025-02-17

D · Potential for more than minimal harm 2025-02-05

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-02-05

E · Potential for more than minimal harm 2023-09-01

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2023-09-13

D · Potential for more than minimal harm 2020-03-18

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2020-04-01

F · Potential for more than minimal harm 2019-03-05