Cycle 1
Health 2023-05-17 · Fire 2023-05-17
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rockwood, TN
Signature Healthcare Of Rockwood Rehab & Wellness
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5580 Roane State Hwy, Rockwood, TN
(865) 354-3366
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
157
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1981-06-26
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
0.59
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,080
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0064
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.11
Baseline 23.62% · Performance 19.27% · Measure score 6.11 · Achievement 4.67 · Improvement 6.11
Healthcare-associated infections
5.59
Baseline 5.45% · Performance 6.16% · Measure score 5.59 · Achievement 5.59 · Improvement 0
Total nurse turnover
8.47
Baseline 37.93% · Performance 29.07% · Measure score 8.47 · Achievement 8.47 · Improvement 6.27
Adjusted total nurse staffing
0.61
Baseline 3.25 hours · Performance 3.25 hours · Measure score 0.61 · Achievement 0.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.04% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 16.55% · Lower 95% interval 10.21% |
| Discharge to community | 53.48% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 46.83% · Lower 95% interval 46.06% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.55% |
95.27%
3.7 pts worse
|
Numerator 65 · Denominator 71 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 71 |
| Discharge self-care score | 69.39% |
53.69%
15.7 pts better
|
Numerator 34 · Denominator 49 |
| Discharge mobility score | 51.02% |
50.94%
0.1 pts better
|
Numerator 25 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 71 · Adjusted rate 1.26% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 3.9% · Lower 95% interval 2.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 36.13% |
42%
5.9 pts worse
|
Numerator 43 · Denominator 119 |
| Discharge function score | 55.1% |
56.45%
1.4 pts worse
|
Numerator 27 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 42 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.62% |
25.2%
3.6 pts worse
|
Numerator 8 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
89.9%
3.2 pts worse
|
93.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.0% · Q2 91.5% · Q3 89.4% · Q4 92.8% · 4Q avg 86.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.3% |
94.5%
7.2 pts worse
|
95.5%
8.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.6%
1.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 3.0% · Q4 2.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.5% |
11.8%
19.7 pts worse
|
11.4%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 41.5% · Q3 24.6% · Q4 31.7% · 4Q avg 31.5% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.2%
3.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 2.1% · Q4 4.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.9% |
32.2%
0.7 pts worse
|
19.6%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 32.7% · Q3 34.7% · Q4 32.0% · 4Q avg 32.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
18.1%
6.4 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.2% · Q3 5.6% · Q4 11.8% · 4Q avg 11.7% · 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 | 16.0% |
19.9%
3.9 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
15.3%
4.3 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 19.1% · Q3 4.9% · Q4 6.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.9%
0.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 2.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
20.2%
1.6 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 19.3% · Q3 16.5% · Q4 17.3% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.4%
1.1 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 6.7% · Q4 6.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
79.6%
4.3 pts better
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 84.4% · Q3 81.8% · Q4 83.2% · 4Q avg 83.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.2%
0.6 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.6%
0.7 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 2.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
79.8%
7.5 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
22.2%
9.2 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 31.0% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-16 · Fire 2019-10-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2018-09-19 · Fire 2018-09-19
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-05-17
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-17
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 2023-06-12
D · Potential for more than minimal harm
2023-05-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-12
F · Potential for more than minimal harm
2019-10-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-11-18
D · Potential for more than minimal harm
2019-10-16
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-11-18
E · Potential for more than minimal harm
2018-09-19
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 2018-10-26
E · Potential for more than minimal harm
2018-09-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-10-26
C · Minimal harm
2018-09-19
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-10-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-05-17
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 2023-06-12
D · Potential for more than minimal harm
2019-10-16
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 2019-11-18
D · Potential for more than minimal harm
2019-10-16
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 2019-11-18
F · Potential for more than minimal harm
2018-09-19
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 2018-10-26
D · Potential for more than minimal harm
2018-09-19
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-19
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 2018-10-26
D · Potential for more than minimal harm
2018-09-19
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 2018-10-26
D · Potential for more than minimal harm
2018-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-26
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
Parker, Roger
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
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1-star overall rating with 1-star inspections with abuse icon flag with $9,318 in total fines with 18 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
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5-star overall rating with 3-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Morgan County
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2-star overall rating with 2-star inspections with $8,512 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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