Cycle 1
Health 2026-01-07 · Fire 2026-01-07
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Jamestown, TN
Signature Healthcare Of Fentress County
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
208 Duncan St North, Jamestown, TN
(931) 879-5859
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1996-01-01
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
0.47
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.75
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
0.22
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,596
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.22
Baseline 20.63% · Performance 19.94% · Measure score 3.22 · Achievement 3.22 · Improvement 1.41
Healthcare-associated infections
0
Baseline 8.14% · Performance 8.44% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.05
Baseline 45.45% · Performance 38.96% · Measure score 6.05 · Achievement 6.05 · Improvement 2.65
Adjusted total nurse staffing
0
Baseline 3.24 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.67% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 17.55% · Lower 95% interval 9.65% |
| Discharge to community | 57.45% |
50.57%
6.9 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 50.36% · Lower 95% interval 49.6% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.44% |
95.27%
2.2 pts better
|
Numerator 114 · Denominator 117 |
| Falls with major injury | 1.71% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 117 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 45 · Denominator 80 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 36 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 0.85% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 117 · Adjusted rate 0.67% |
| Healthcare-associated infections requiring hospitalization | 8.44% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 10.38% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 5.43% |
8.2%
2.8 pts worse
|
Numerator 5 · Denominator 92 |
| Staff flu vaccination coverage | 24.81% |
42%
17.2 pts worse
|
Numerator 32 · Denominator 129 |
| Discharge function score | 58.75% |
56.45%
2.3 pts better
|
Numerator 47 · Denominator 80 |
| Transfer of health information to provider | 91.55% |
95.95%
4.4 pts worse
|
Numerator 65 · Denominator 71 |
| 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 | 24.59% |
25.2%
0.6 pts worse
|
Numerator 15 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
89.9%
9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 98.9% |
| 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 | 5.4% |
3.6%
1.8 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 6.1% · Q3 4.5% · Q4 2.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.9% |
11.8%
3.1 pts worse
|
11.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 8.2% · Q3 11.7% · Q4 19.1% · 4Q avg 14.9% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 1.6% · Q3 0.0% · Q4 9.2% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
32.2%
2.5 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 35.5% · Q3 33.9% · Q4 32.8% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 34.3% |
18.1%
16.2 pts worse
|
16.7%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 23.9% · Q3 37.3% · Q4 40.4% · 4Q avg 34.3% · 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 18.2% · Q2 17.4% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.3%
2.5 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 7.5% · Q3 13.2% · Q4 15.3% · 4Q avg 12.8% · 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 1.5% · Q3 0.0% · 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 | 18.4% |
20.2%
1.8 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 17.2% · Q3 22.1% · Q4 18.3% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.4%
1.8 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 4.3% · Q4 8.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
79.6%
14.4 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 92.9% · Q3 95.0% · Q4 96.2% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
11.2%
3.9 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 15.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.6%
About the same
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.7% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
79.8%
15.8 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
22.2%
5.8 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 16.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-15 · Fire 2022-06-15
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-05-15 · Fire 2019-05-15
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
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 2026-02-04
D · Potential for more than minimal harm
2026-01-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-04
D · Potential for more than minimal harm
2022-06-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-01
F · Potential for more than minimal harm
2019-05-15
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 2019-06-03
D · Potential for more than minimal harm
2019-05-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-05-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-07
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 2026-01-16
D · Potential for more than minimal harm
2026-01-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-16
D · Potential for more than minimal harm
2026-01-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-16
D · Potential for more than minimal harm
2026-01-07
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2026-01-16
D · Potential for more than minimal harm
2024-02-23
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 2024-03-29
D · Potential for more than minimal harm
2024-02-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-04-03
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-05-04
E · Potential for more than minimal harm
2022-06-15
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 2022-07-12
E · Potential for more than minimal harm
2022-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2022-06-15
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 2022-07-12
D · Potential for more than minimal harm
2019-05-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-06-14
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
Mckenney, Allison
W-2 Managing Employee · Individual
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
Pickett Care And Rehabilitation Center
Byrdstown, TN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Clinton County Care and Rehabilitation Center
Albany, KY
4-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Overton County Health And Rehab Center
Livingston, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out