Cycle 1
Health 2023-09-22 · Fire 2023-09-22
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Oneida, TN
Oneida Nursing And Rehab Center
1-star overall rating with 1-star inspections with Special Focus status with $52,111 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
18805 Alberta Dr, Oneida, TN
(423) 569-8382
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-01-07
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
0.53
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,084
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.76% · Performance 24.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.99% · Performance 9.37% · 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
2.55
Baseline 3.06 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 2.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.38% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 16.67% · Lower 95% interval 8.98% |
| Discharge to community | 45.88% |
50.57%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 38.38% · Lower 95% interval 34.8% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 78 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 48.98% |
53.69%
4.7 pts worse
|
Numerator 24 · Denominator 49 |
| Discharge mobility score | 22.45% |
50.94%
28.5 pts worse
|
Numerator 11 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 80 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.37% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 12.79% · Lower 95% interval 5.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 42.17% |
42%
0.2 pts better
|
Numerator 35 · Denominator 83 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 21 · Denominator 49 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 9 · Denominator 39 |
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 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
1.6
2.3 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 5.1 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
89.9%
3.7 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 76.7% · 4Q avg 93.6% |
| 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 | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long 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 long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 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 who lose too much weight | 2.2% |
6.2%
4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 7.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.1% |
32.2%
2.9 pts worse
|
19.6%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 39.1% · Q3 32.0% · Q4 29.6% · 4Q avg 35.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
18.1%
4 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 10.0% · 4Q avg 14.1% · 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 | 11.7% |
19.9%
8.2 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.8% |
15.3%
16.5 pts worse
|
14.9%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 42.9% · Q4 20.0% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.6% |
0.9%
4.7 pts worse
|
1.0%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.1% · Q3 6.3% · Q4 6.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
1.9%
3.8 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 8.0% · Q4 6.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
20.2%
2.5 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 37.1% · Q3 34.2% · Q4 0.0% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.4%
2.2 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 12.5% · Q4 14.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
79.6%
15.9 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 98.6% · Q3 98.5% · Q4 87.3% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.1% |
11.2%
14.9 pts worse
|
12.0%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 26.6% · Expected 11.3% · 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 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
79.8%
17.5 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
22.2%
4.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 26.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-24 · Fire 2020-01-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-11-28 · Fire 2018-11-28
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-22
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 2023-10-06
Inspection history
Recent health citations
K · Immediate jeopardy
2023-09-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-07
K · Immediate jeopardy
2023-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-09
K · Immediate jeopardy
2023-09-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-09
F · Potential for more than minimal harm
2023-09-22
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 2023-10-09
D · Potential for more than minimal harm
2023-09-22
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 2023-09-29
D · Potential for more than minimal harm
2023-09-22
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 2023-10-20
D · Potential for more than minimal harm
2023-09-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
D · Potential for more than minimal harm
2018-11-28
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 2018-12-07
Penalties and ownership
What sits behind the stars
$52,111
2023-09-22
Fine
Fine · fine $52,111
Fine
Ownership
Defoor, Perry
5% Or Greater Direct Ownership Interest · Individual
Defoor, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Chitwood, Angela
W-2 Managing Employee · Individual
Grace Healthcare, LLC
Operational/Managerial Control · Organization
Holcombe, Michelle
Operational/Managerial Control · Individual
Taylor, Craig
Corporate Officer · Individual
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#3
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