Cycle 1
Health 2025-12-04 · Fire 2025-12-04
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Portland, TN
Signature Health Of Portland Rehab & Wellness Cent
1-star overall rating with 1-star inspections with abuse icon flag with $107,228 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
215 Highland Circle Drive, Portland, TN
(615) 325-9263
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1993-01-01
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
0.78
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,951
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.83
Baseline 21.71% · Performance 20.15% · Measure score 2.83 · Achievement 2.77 · Improvement 2.83
Healthcare-associated infections
7.28
Baseline 6.55% · Performance 5.66% · Measure score 7.28 · Achievement 7.28 · Improvement 5.23
Total nurse turnover
2.38
Baseline 60.00% · Performance 53.97% · Measure score 2.38 · Achievement 2.38 · Improvement 1.22
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 2.45 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.77% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 20.21% · Lower 95% interval 8.66% |
| Discharge to community | 50.62% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 89 · Observed rate 39.33% · Lower 95% interval 38.94% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 5.66% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 1.75% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 4.26% |
42%
37.7 pts worse
|
Numerator 6 · Denominator 141 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.5% |
3.6%
2.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 0.0% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.8% |
11.8%
8 pts worse
|
11.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 11.1% · Q3 21.7% · Q4 25.0% · 4Q avg 19.8% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.2%
0.5 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 9.3% · Q4 7.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.4% |
32.2%
2.2 pts worse
|
19.6%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 31.5% · Q3 35.2% · Q4 36.5% · 4Q avg 34.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
18.1%
8.3 pts worse
|
16.7%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 25.6% · Q3 25.6% · Q4 25.6% · 4Q avg 26.4% · 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 | 13.6% |
19.9%
6.3 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
15.3%
10 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 1.9% · Q3 7.7% · Q4 2.0% · 4Q avg 5.3% · 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 | 0.4% |
1.9%
1.5 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.9% |
20.2%
6.3 pts better
|
19.8%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.9% · Q3 9.6% · Q4 18.6% · 4Q avg 13.9% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.4%
1.5 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.5% · Q3 7.8% · Q4 4.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
79.6%
11 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 92.5% · Q3 84.6% · Q4 85.0% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 9.1% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.6%
1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
79.8%
8.3 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.9% |
22.2%
12.7 pts worse
|
23.9%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.9% · Observed 40.9% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-29 · Fire 2020-01-29
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-04
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-12-04
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K321 · Smoke Deficiencies
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 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-31
G · Actual harm
2025-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-03-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-29
D · Potential for more than minimal harm
2020-01-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K321 · Smoke Deficiencies
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 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-03-10
D · Potential for more than minimal harm
2019-02-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-03-04
D · Potential for more than minimal harm
2019-02-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-03-04
Inspection history
Recent health citations
G · Actual harm
2025-12-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
G · Actual harm
2025-09-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-26
J · Immediate jeopardy
2025-04-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-06
J · Immediate jeopardy
2025-04-11
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-01-20
J · Immediate jeopardy
2025-04-11
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 2025-05-06
F · Potential for more than minimal harm
2025-04-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-11
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 2025-05-06
D · Potential for more than minimal harm
2025-04-11
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-05-06
J · Immediate jeopardy
2024-08-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-31
J · Immediate jeopardy
2024-08-23
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 2024-08-31
J · Immediate jeopardy
2024-08-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-08-31
F · Potential for more than minimal harm
2020-01-29
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 2020-03-11
D · Potential for more than minimal harm
2020-01-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-29
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 2020-03-11
D · Potential for more than minimal harm
2020-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2020-03-11
G · Actual harm
2019-02-07
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 2019-02-13
E · Potential for more than minimal harm
2019-02-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-03-04
E · Potential for more than minimal harm
2019-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-03-04
D · Potential for more than minimal harm
2019-02-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-04
D · Potential for more than minimal harm
2019-02-07
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 2019-03-04
C · Minimal harm
2019-02-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-03-04
Penalties and ownership
What sits behind the stars
$91,582
2025-04-11
Fine
Fine · fine $91,582
Fine
$7,823
2024-08-23
Fine
Fine · fine $7,823
Fine
$7,823
2024-08-23
Fine
Fine · fine $7,823
Fine
$0
2024-08-23
Payment Denial
Payment Denial · denial start 2024-08-29 · 2 days
2 day denial
Ownership
Distinct Group Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
Masden, Tyler
W-2 Managing Employee · Individual
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
Gallatin Center For Rehabilitation And Healing
Gallatin, TN
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Waters Of Gallatin, LLC
Gallatin, TN
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
White House Health Care Inc
White House, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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