3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Livingston, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
318 Bilbrey Street, Livingston, TN
(931) 823-6403
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
87
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.30
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.53
Nurse aide staffing
Weekend hours
3.52
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.9%
9.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
11.8%
11.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.2%
3.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
32.2%
4.6 pts better
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
18.1%
6.4 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.8% |
19.9%
16.9 pts worse
|
16.3%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
15.3%
11.6 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.9%
0.8 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
20.2%
10.9 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
5.4%
4.4 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
79.6%
18.6 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.2%
4.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.6%
1.1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
79.8%
16.6 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
22.2%
0.9 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-30
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-06-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-30
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-30
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-12-31
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-31
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 2019-12-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-31
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-12-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-12-05
Inspection history
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 2025-06-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-23
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-12-28
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 2018-12-28
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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