Cycle 1
Health 2025-04-09 · Fire 2025-04-09
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Byrdstown, TN
Pickett Care And Rehabilitation Center
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
129 Hillcrest Drive, Byrdstown, TN
(931) 864-3162
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
69
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1997-04-01
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
0.60
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.24
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.99
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
0.22
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,620
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.35
Baseline 21.62% · Performance 19.42% · Measure score 4.35 · Achievement 4.35 · Improvement 4.29
Healthcare-associated infections
2.28
Baseline 6.22% · Performance 7.15% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Total nurse turnover
5.35
Baseline 38.89% · Performance 41.82% · Measure score 5.35 · Achievement 5.35 · Improvement 0
Adjusted total nurse staffing
2.23
Baseline 3.49 hours · Performance 3.71 hours · Measure score 2.23 · Achievement 2.23 · Improvement 0.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 4.82% · Lower 95% interval 6.55% |
| Discharge to community | 54.62% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 48.05% · Lower 95% interval 44.97% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 15 · Denominator 33 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 15 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 1.95% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 58 |
| Staff flu vaccination coverage | 12.77% |
42%
29.2 pts worse
|
Numerator 12 · Denominator 94 |
| Discharge function score | 54.55% |
56.45%
1.9 pts worse
|
Numerator 18 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.82% |
25.2%
6.6 pts better
|
Numerator 7 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.9%
9.1 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.9% · Q4 97.9% · 4Q avg 99.0% |
| 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 | 3.1% |
3.6%
0.5 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.0% · Q3 2.1% · Q4 4.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
11.8%
7.9 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.7% · Q4 7.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.2%
3.4 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.3% · Q3 4.5% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
32.2%
9.5 pts better
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 21.7% · Q3 23.4% · Q4 19.1% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.6% |
18.1%
15.5 pts worse
|
16.7%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 40.0% · Q3 36.1% · Q4 22.2% · 4Q avg 33.6% · 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 | 6.9% |
19.9%
13 pts better
|
16.3%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.2% · Q3 10.5% · Q4 3.5% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.0% |
15.3%
6.3 pts better
|
14.9%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 14.0% · Q3 8.9% · Q4 8.7% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 21.6% |
20.2%
1.4 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 22.8% · Q3 21.2% · Q4 18.9% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.4%
1.9 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 10.4% · Q3 9.9% · Q4 6.1% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
79.6%
17.3 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 95.1% · Q3 100.0% · Q4 98.4% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
11.2%
4.7 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.6%
2 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q3 3.4% · Q4 2.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.4% |
22.2%
6.8 pts better
|
23.9%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 13.3% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-17 · Fire 2021-11-17
9 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-14 · Fire 2019-08-14
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-09
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-14
E · Potential for more than minimal harm
2019-08-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-15
D · Potential for more than minimal harm
2019-08-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-09
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 2025-05-14
D · Potential for more than minimal harm
2025-04-09
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 2025-05-14
D · Potential for more than minimal harm
2025-04-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-09
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-02-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-12
D · Potential for more than minimal harm
2021-11-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-17
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-17
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 2021-12-10
D · Potential for more than minimal harm
2021-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-11-17
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 2021-12-10
G · Actual harm
2019-08-14
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 2019-11-19
G · Actual harm
2019-08-14
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 2019-11-19
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
Foster, Noah
W-2 Managing Employee · Individual
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Signature Healthcare LLC
Operational/Managerial Control · Organization
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
Clinton County Care and Rehabilitation Center
Albany, KY
4-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Signature Healthcare Of Fentress County
Jamestown, TN
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Overton County Health And Rehab Center
Livingston, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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