Cycle 1
Health 2023-09-27 · Fire 2023-09-27
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cleveland, TN
Signature Healthcare Of Cleveland
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2750 Executive Park Place, Cleveland, TN
(423) 476-4444
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1996-03-01
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
0.53
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,009
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0162
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.62% · Performance 16.42% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.73
Baseline 5.11% · Performance 5.53% · Measure score 7.73 · Achievement 7.73 · Improvement 0
Total nurse turnover
6.71
Baseline 38.03% · Performance 36.25% · Measure score 6.71 · Achievement 6.71 · Improvement 0.85
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 2.82 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 302 · Observed rate 10.93% · Lower 95% interval 8.69% |
| Discharge to community | 64.79% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 285 · Observed rate 60.35% · Lower 95% interval 59.45% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 79.59% |
95.27%
15.7 pts worse
|
Numerator 78 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 97 |
| Discharge self-care score | 71.95% |
53.69%
18.3 pts better
|
Numerator 59 · Denominator 82 |
| Discharge mobility score | 70.73% |
50.94%
19.8 pts better
|
Numerator 58 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 97 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 5.53% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 3.78% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 1.94% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 103 |
| Staff flu vaccination coverage | 4.43% |
42%
37.6 pts worse
|
Numerator 7 · Denominator 158 |
| Discharge function score | 74.39% |
56.45%
17.9 pts better
|
Numerator 61 · Denominator 82 |
| Transfer of health information to provider | 97.87% |
95.95%
1.9 pts better
|
Numerator 46 · Denominator 47 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 40 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 2.22% |
25.2%
23 pts worse
|
Numerator 1 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.9%
9.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 98.4% · 4Q avg 99.2% |
| 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 | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.1% · Q3 3.2% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
11.8%
6.3 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.3% · Q3 6.7% · Q4 7.0% · 4Q avg 5.5% |
| 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 0.0% · Q2 5.0% · Q3 0.0% · Q4 7.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
32.2%
9.7 pts better
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 21.7% · Q3 20.7% · Q4 17.5% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
18.1%
3.1 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 23.4% · Q3 21.8% · Q4 13.5% · 4Q avg 21.2% · 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 | 16.5% |
19.9%
3.4 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 18.3% · Q3 3.5% · Q4 0.0% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
15.3%
0.6 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.2% · Q2 18.5% · Q3 5.5% · Q4 1.9% · 4Q avg 15.9% · 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 | 0.8% |
1.9%
1.1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
20.2%
4.2 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 28.8% · Q3 27.9% · Q4 13.2% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
5.4%
3.6 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.5% · Q3 2.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
79.6%
19.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 99.1% · Q4 97.7% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.2%
4.9 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.6%
0.9 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
79.8%
19.8 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
22.2%
3.2 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 18.9% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-08 · Fire 2020-01-08
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-01-24 · Fire 2019-01-24
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-24
F · Potential for more than minimal harm
2023-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-24
F · Potential for more than minimal harm
2020-01-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-02-06
D · Potential for more than minimal harm
2020-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-06
F · Potential for more than minimal harm
2019-01-24
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-02-12
F · Potential for more than minimal harm
2019-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-02-12
D · Potential for more than minimal harm
2019-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-12
D · Potential for more than minimal harm
2019-01-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-02-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-09-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
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 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-27
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 2023-10-27
D · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-27
D · Potential for more than minimal harm
2020-01-08
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 2020-02-06
D · Potential for more than minimal harm
2019-01-24
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-02-12
D · Potential for more than minimal harm
2019-01-24
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 2019-02-12
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
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Spence, Jaquelyne
Operational/Managerial Control · Individual
Spence, Jaquelyne
W-2 Managing Employee · 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
Bradley Health Care & Rehab
Cleveland, TN
4-star overall rating with 4-star inspections with $8,999 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Cleveland
Cleveland, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Tennessee State Veterans Home- Cleveland
Cleveland, TN
5-star overall rating with 5-star inspections with 3 recent health deficiencies
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