Cycle 1
Health 2025-03-27 · Fire 2025-03-27
4 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Lebanon, TN
Pavilion-Ths, LLC
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1406 Medical Center Drive, Lebanon, TN
(615) 444-2882
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-12-17
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
0.51
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,055
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.31
Baseline 18.22% · Performance 18.51% · Measure score 6.31 · Achievement 6.31 · Improvement 0
Healthcare-associated infections
2.96
Baseline 6.33% · Performance 6.95% · Measure score 2.96 · Achievement 2.96 · 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 3.80 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 225 · Observed rate 7.56% · Lower 95% interval 7.46% |
| Discharge to community | 69.83% |
50.57%
19.3 pts better
|
Better than the National Rate · Eligible stays 223 · Observed rate 71.3% · Lower 95% interval 64.05% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 125 · Denominator 125 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 1 · Denominator 125 |
| Discharge self-care score | 62.62% |
53.69%
8.9 pts better
|
Numerator 67 · Denominator 107 |
| Discharge mobility score | 44.86% |
50.94%
6.1 pts worse
|
Numerator 48 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 5 · Denominator 125 · Adjusted rate 4.8% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 5.44% · Lower 95% interval 4.62% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 32.47% |
42%
9.5 pts worse
|
Numerator 25 · Denominator 77 |
| Discharge function score | 57.01% |
56.45%
0.6 pts better
|
Numerator 61 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 98.04% |
96.28%
1.8 pts better
|
Numerator 50 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 31.88% |
25.2%
6.7 pts better
|
Numerator 22 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.9%
6.6 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 94.1% · Q3 97.2% · Q4 94.3% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
94.5%
0.4 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 2.1% · 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 | 11.0% |
6.2%
4.8 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 16.1% · Q3 0.0% · Q4 3.2% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.7% |
32.2%
3.5 pts worse
|
19.6%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 34.4% · Q3 40.6% · Q4 29.0% · 4Q avg 35.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
18.1%
2.9 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 11.5% · Q3 12.0% · Q4 20.8% · 4Q avg 15.2% · 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 | 33.6% |
19.9%
13.7 pts worse
|
16.3%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.8% |
15.3%
15.5 pts worse
|
14.9%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 25.9% · Q3 28.0% · Q4 48.1% · 4Q avg 30.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.9%
0.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.8% |
20.2%
15.6 pts worse
|
19.8%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.5% · Q2 33.0% · Q3 33.1% · Q4 34.3% · 4Q avg 35.8% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.4%
1.9 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 0.0% · Q3 5.3% · Q4 2.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
79.6%
5.3 pts better
|
81.7%
3.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 91.6% · Q3 86.1% · Q4 71.9% · 4Q avg 84.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.2%
4.5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.6% · Expected 9.3% · 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 | 63.1% |
79.8%
16.7 pts worse
|
79.7%
16.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
22.2%
8.3 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 10.4% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-29 · Fire 2019-10-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-07 · Fire 2018-11-07
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-27
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-01
D · Potential for more than minimal harm
2019-10-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-13
C · Minimal harm
2018-11-07
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-12-19
C · Minimal harm
2018-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
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 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F578 · Resident Rights Deficiencies
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 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-21
D · Potential for more than minimal harm
2019-10-29
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 2019-11-15
D · Potential for more than minimal harm
2018-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-23
D · Potential for more than minimal harm
2018-11-07
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-11-23
Penalties and ownership
What sits behind the stars
Ownership
Pavilion-Ths, LLC
5% Or Greater Direct Ownership Interest · Organization
Bone, Harold
Corporate Officer · Individual
Bone, Margaret
Corporate Officer · Individual
L4 Lifestyles LLC
Operational/Managerial Control · Organization
Njezic, Joseph
Operational/Managerial Control · Individual
Njezic, Joseph
W-2 Managing Employee · Individual
Pound, Kevin
Operational/Managerial Control · Individual
Stein & Associates LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lebanon Center For Rehabilitation And Healing, LLC
Lebanon, TN
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#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
Jump out