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
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
0.90
Licensed practical nurse staffing
Aide hours / resident day
2.12
Nurse aide staffing
Weekend hours
2.94
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
40%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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