Cycle 1
Health 2022-05-19 · Fire 2022-05-19
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tiptonville, TN
Reelfoot Manor Health And Rehab
1-star overall rating with 2-star inspections with 14 recent health deficiencies
1034 Reelfoot Drive, Tiptonville, TN
(731) 253-6681
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
116
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Communities
Operator or chain grouping
Approved since
1992-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
40 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.58
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
1.81
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,125
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9941
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.61
Baseline 19.66% · Performance 19.30% · Measure score 4.61 · Achievement 4.61 · Improvement 0.87
Healthcare-associated infections
4.25
Baseline 8.28% · Performance 6.72% · Measure score 4.25 · Achievement 3.74 · Improvement 4.25
Total nurse turnover
7.61
Baseline 37.74% · Performance 32.56% · Measure score 7.61 · Achievement 7.61 · Improvement 3.52
Adjusted total nurse staffing
0
Baseline 3.10 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 10% · Lower 95% interval 7.33% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 8.33% |
95.27%
86.9 pts worse
|
Numerator 3 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 18.18% |
53.69%
35.5 pts worse
|
Numerator 4 · Denominator 22 |
| Discharge mobility score | 22.73% |
50.94%
28.2 pts worse
|
Numerator 5 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 3 · Denominator 36 · Adjusted rate 6.4% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 60 |
| Staff flu vaccination coverage | 30.77% |
42%
11.2 pts worse
|
Numerator 24 · Denominator 78 |
| Discharge function score | 22.73% |
56.45%
33.7 pts worse
|
Numerator 5 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.17% |
25.2%
4 pts better
|
Numerator 7 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.6
1.1 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.6
1.8 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
89.9%
7 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 89.1% · 4Q avg 96.9% |
| 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 3.6% · Q2 2.0% · Q3 2.3% · Q4 4.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
11.8%
8.2 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.4% · Q3 2.9% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.2%
3.1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 2.0% · Q3 2.4% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
32.2%
7.1 pts better
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 22.0% · Q3 18.2% · Q4 30.4% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.1% |
18.1%
13 pts worse
|
16.7%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 29.6% · Q3 32.1% · Q4 34.5% · 4Q avg 31.1% · 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 | 28.9% |
19.9%
9 pts worse
|
16.3%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
15.3%
8.9 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 19.5% · Q3 30.6% · Q4 20.5% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.0% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
1.9%
3.3 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 10.0% · Q3 7.1% · Q4 2.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
20.2%
5.2 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 19.8% · Q3 30.3% · Q4 37.6% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.4%
0.4 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.3% · Q3 5.0% · Q4 7.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 27.8% |
79.6%
51.8 pts worse
|
81.7%
53.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 27.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.4% |
11.2%
8.2 pts worse
|
12.0%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 23.1% · Expected 13.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
22.2%
6.2 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 15.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-15 · Fire 2020-01-15
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-03-06 · Fire 2019-03-06
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (9 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-29
D · Potential for more than minimal harm
2019-03-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-04-20
C · Minimal harm
2019-03-06
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-04-20
Inspection history
Recent health citations
G · Actual harm
2022-05-19
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 2022-06-30
E · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
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 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-06-30
D · Potential for more than minimal harm
2020-01-15
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 2020-02-29
D · Potential for more than minimal harm
2020-01-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-02-29
E · Potential for more than minimal harm
2019-03-06
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 2019-04-20
E · Potential for more than minimal harm
2019-03-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-20
E · Potential for more than minimal harm
2019-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
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 2019-04-20
D · Potential for more than minimal harm
2019-03-06
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 2019-04-20
D · Potential for more than minimal harm
2019-03-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
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 2019-04-20
D · Potential for more than minimal harm
2019-03-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-04-20
Penalties and ownership
What sits behind the stars
Ownership
Gbd LLC
5% Or Greater Direct Ownership Interest · Organization
Barnes, Michelle
Operational/Managerial Control · Individual
Barres, LLC
5% Or Greater Indirect Ownership Interest · Organization
Crino, Bryan
5% Or Greater Indirect Ownership Interest · Individual
Feuer, Scott
5% Or Greater Indirect Ownership Interest · Individual
Gbd LLC
Operational/Managerial Control · Organization
Lindeman, Stuart
5% Or Greater Indirect Ownership Interest · Individual
Lindeman, Stuart
Corporate Officer · Individual
Mission Health Of Georgia, LLC
Operational/Managerial Control · Organization
Passero, Joseph
5% Or Greater Indirect Ownership Interest · Individual
T And C Capital Assets, LLC
5% Or Greater Indirect Ownership Interest · Organization
Windward Health Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Yoakum, Jamie
Operational/Managerial Control · Individual
Yoakum, Jamie
Corporate Officer · Individual
Nearby options
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#2
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#3
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