Cycle 1
Health 2023-08-10 · Fire 2023-08-10
8 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lebanon, TN
Quality Center For Rehabilitation And Healing LLC
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
932 Baddour Parkway, Lebanon, TN
(615) 444-1836
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
280
Certified beds
Average residents
254
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1983-01-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.35
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.22
Baseline 19.44% · Performance 19.01% · Measure score 5.22 · Achievement 5.22 · Improvement 1.28
Healthcare-associated infections
1.18
Baseline 8.42% · Performance 7.84% · Measure score 1.18 · Achievement 0 · Improvement 1.18
Total nurse turnover
4.85
Baseline 53.81% · Performance 43.87% · Measure score 4.85 · Achievement 4.85 · Improvement 2.93
Adjusted total nurse staffing
0
Baseline 3.04 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 9.09% · Lower 95% interval 7.36% |
| Discharge to community | 56.65% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 50.93% · Lower 95% interval 48.32% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 202 · Denominator 202 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 202 |
| Discharge self-care score | 47.71% |
53.69%
6 pts worse
|
Numerator 73 · Denominator 153 |
| Discharge mobility score | 41.18% |
50.94%
9.8 pts worse
|
Numerator 63 · Denominator 153 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 199 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.84% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 8.22% · Lower 95% interval 5.02% |
| Staff COVID-19 vaccination coverage | 7.18% |
8.2%
1 pts worse
|
Numerator 26 · Denominator 362 |
| Staff flu vaccination coverage | 28.18% |
42%
13.8 pts worse
|
Numerator 122 · Denominator 433 |
| Discharge function score | 50.98% |
56.45%
5.5 pts worse
|
Numerator 78 · Denominator 153 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 98.89% |
96.28%
2.6 pts better
|
Numerator 89 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 31.93% |
25.2%
6.7 pts better
|
Numerator 38 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.9%
9.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.4% · Q3 5.5% · Q4 5.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
11.8%
9.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.5% · Q4 5.5% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.9% · Q3 2.0% · Q4 3.6% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.4% |
32.2%
4.2 pts worse
|
19.6%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.3% · Q2 39.8% · Q3 34.5% · Q4 33.2% · 4Q avg 36.4% |
| 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 | 12.2% |
19.9%
7.7 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 12.5% · Q3 14.5% · Q4 10.7% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
15.3%
4.8 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.1% · Q3 8.8% · Q4 9.6% · 4Q avg 10.5% · 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 | 0.3% |
1.9%
1.6 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.4% |
20.2%
6.8 pts better
|
19.8%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 16.1% · Q3 11.0% · Q4 10.9% · 4Q avg 13.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.4%
2.5 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.4% · Q3 2.6% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
79.6%
17.5 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.2% · Q3 97.6% · Q4 99.3% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
11.2%
5.8 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.4% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.6%
1.3 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
79.8%
15.5 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.2%
1.8 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 23.9% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-08 · Fire 2019-05-08
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-05-03 · Fire 2018-05-03
13 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-08-10
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-08-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-31
D · Potential for more than minimal harm
2019-05-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-05-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-10
D · Potential for more than minimal harm
2018-05-03
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-05-23
C · Minimal harm
2018-05-03
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-10-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-22
G · Actual harm
2023-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-10
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 2023-09-07
D · Potential for more than minimal harm
2023-08-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-10
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-09-07
G · Actual harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2023-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
E · Potential for more than minimal harm
2019-05-08
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 2019-06-10
D · Potential for more than minimal harm
2019-05-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-06-10
F · Potential for more than minimal harm
2018-05-03
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 2018-05-23
E · Potential for more than minimal harm
2018-05-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
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 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
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 2018-05-23
D · Potential for more than minimal harm
2018-05-03
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 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-05-23
C · Minimal harm
2018-05-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-05-23
Penalties and ownership
What sits behind the stars
$13,305
2023-08-10
Fine
Fine · fine $13,305
Fine
$0
2023-08-10
Payment Denial
Payment Denial · denial start 2023-09-07 · 54 days
54 day denial
$7,901
2023-03-22
Fine
Fine · fine $7,901
Fine
Ownership
Quality Tn Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Md Friedman Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Neal Einhorn Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Zucker, Yossie
5% Or Greater Indirect Ownership Interest · Individual
Eme, Ijagha
Operational/Managerial Control · Individual
Friedman, Mark
Corporate Officer · Individual
Grisham, Julie
Operational/Managerial Control · Individual
Quality Tn Ventures LLC
Operational/Managerial Control · Organization
Washer, Stephanie
Operational/Managerial Control · Individual
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
Pavilion-Ths, LLC
Lebanon, TN
5-star overall rating with 4-star inspections with 4 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