Cycle 1
Health 2022-10-19 · Fire 2022-10-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Mountain City, TN
Mountain City Care & Rehabilitation Center
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
919 Medical Park Drive, Mountain City, TN
(423) 727-7800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1988-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 facilities
Chain averages 3 overall / 3 health / 3 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
0.63
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.61
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
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
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,803
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.50
Baseline 20.74% · Performance 19.35% · Measure score 4.50 · Achievement 4.50 · Improvement 3.25
Healthcare-associated infections
0
Baseline 7.39% · Performance 8.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.05
Baseline 36.07% · Performance 43.06% · Measure score 5.05 · Achievement 5.05 · Improvement 0
Adjusted total nurse staffing
0.72
Baseline 3.06 hours · Performance 3.28 hours · Measure score 0.72 · Achievement 0.72 · Improvement 0.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 6.15% · Lower 95% interval 5.64% |
| Discharge to community | 50.35% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 48.21% · Lower 95% interval 38.54% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 3.66% |
| Healthcare-associated infections requiring hospitalization | 8.76% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 87 |
| Staff flu vaccination coverage | 12.96% |
42%
29 pts worse
|
Numerator 14 · Denominator 108 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · 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 | 4.6% |
3.6%
1 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.6% · Q3 3.0% · Q4 4.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
11.8%
1.9 pts better
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 8.8% · Q3 10.7% · Q4 8.3% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
6.2%
4.9 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
32.2%
5.6 pts better
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 21.3% · Q3 31.0% · Q4 30.2% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
18.1%
1 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 22.9% · Q3 14.9% · Q4 17.0% · 4Q avg 19.1% · 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 | 13.0% |
19.9%
6.9 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 0.0% · Q3 15.5% · Q4 17.7% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
15.3%
7 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.3% · Q3 8.8% · Q4 13.5% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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 1.5% · Q2 3.1% · Q3 0.0% · 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 | 18.3% |
20.2%
1.9 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 27.9% · Q3 16.9% · Q4 13.3% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.4%
1.4 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 8.9% · Q3 2.7% · Q4 7.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
79.6%
13.8 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 94.6% · Q3 96.2% · Q4 93.5% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.2%
5.1 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.5% · Expected 11.8% · 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 | 79.7% |
79.8%
0.1 pts worse
|
79.7%
About the same
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
22.2%
3.1 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 25.8% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-02 · Fire 2019-10-02
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2018-10-11 · Fire 2018-10-11
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 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
2022-10-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-19
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 2022-10-28
D · Potential for more than minimal harm
2022-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-28
D · Potential for more than minimal harm
2019-10-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-01
F · Potential for more than minimal harm
2018-10-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-11-16
C · Minimal harm
2018-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-11-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-10-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-27
E · Potential for more than minimal harm
2019-10-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-02
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 2019-10-26
D · Potential for more than minimal harm
2019-10-02
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 2019-10-26
D · Potential for more than minimal harm
2019-10-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-01
E · Potential for more than minimal harm
2018-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-11
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 2018-11-16
D · Potential for more than minimal harm
2018-10-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-11-16
Penalties and ownership
What sits behind the stars
Ownership
Lp Cr Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Agemo Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Rife, James
W-2 Managing Employee · Individual
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Abingdon Health Care LLC
Abingdon, VA
5-star overall rating with 5-star inspections with 3 recent health deficiencies
#2
Deer Meadows Rehabilitation And Nursing
Abingdon, VA
1-star overall rating with 1-star inspections with 36 recent health deficiencies
#3
The Rehab Center At Bristol
Bristol, VA
1-star overall rating with 2-star inspections with $10,358 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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