Cycle 1
Health 2024-10-16 · Fire 2024-10-16
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
South Pittsburg, TN
Signature Healthcare Of South Pittsburg Rehab & We
3-star overall rating with 2-star inspections with abuse icon flag with $20,050 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
201 East 10th Street, South Pittsburg, TN
(423) 837-7981
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
165
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1995-03-01
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
0.73
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.61
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,105
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.81
Baseline 22.20% · Performance 21.01% · Measure score 1.81 · Achievement 0.91 · Improvement 1.81
Healthcare-associated infections
1.26
Baseline 9.22% · Performance 8.48% · Measure score 1.26 · Achievement 0 · Improvement 1.26
Total nurse turnover
10
Baseline 31.15% · Performance 22.22% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.53
Baseline 3.08 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.32% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 18.52% · Lower 95% interval 8.82% |
| Discharge to community | 58.63% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 50.79% · Lower 95% interval 46.1% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 90.32% |
53.69%
36.6 pts better
|
Numerator 28 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 2.26% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 14.63% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 2 · Denominator 76 |
| Staff flu vaccination coverage | 44.83% |
42%
2.8 pts better
|
Numerator 39 · Denominator 87 |
| Discharge function score | 74.19% |
56.45%
17.7 pts better
|
Numerator 23 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 88% |
96.28%
8.3 pts worse
|
Numerator 22 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 30.43% |
25.2%
5.2 pts better
|
Numerator 7 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.7 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 45.1% |
89.9%
44.8 pts worse
|
93.4%
48.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.3% · Q2 44.9% · Q3 40.3% · Q4 47.7% · 4Q avg 45.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
94.5%
2.1 pts worse
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.8% · Q3 3.0% · Q4 1.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.3% |
11.8%
10.5 pts worse
|
11.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 20.0% · Q3 43.5% · Q4 23.7% · 4Q avg 22.3% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
6.2%
5.4 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
32.2%
7.1 pts better
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 24.6% · Q3 23.3% · Q4 26.7% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
18.1%
6.3 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.9% · Q3 6.8% · Q4 16.3% · 4Q avg 11.8% · 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 | 15.3% |
19.9%
4.6 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
15.3%
1.7 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.1% · Q2 7.0% · Q3 6.9% · Q4 12.5% · 4Q avg 17.0% · 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 | 17.3% |
20.2%
2.9 pts better
|
19.8%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 20.0% · Q3 19.5% · Q4 12.9% · 4Q avg 17.3% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.4%
About the same
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.3% · Q3 5.6% · Q4 6.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.1% |
79.6%
8.5 pts worse
|
81.7%
10.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 70.8% · Q3 72.9% · Q4 81.1% · 4Q avg 71.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.2%
1.9 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 10.3% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
79.8%
13.1 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
22.2%
7 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 30.8% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-01 · Fire 2021-12-01
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-03-27 · Fire 2019-03-27
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-16
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-16
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 2024-10-24
D · Potential for more than minimal harm
2024-10-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-24
E · Potential for more than minimal harm
2021-12-01
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 2021-12-31
D · Potential for more than minimal harm
2019-03-27
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-04-18
D · Potential for more than minimal harm
2019-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-04-18
Inspection history
Recent health citations
G · Actual harm
2024-10-16
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 2024-11-04
E · Potential for more than minimal harm
2024-10-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-16
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 2024-11-04
D · Potential for more than minimal harm
2024-10-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
G · Actual harm
2023-09-21
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 2023-06-09
D · Potential for more than minimal harm
2023-09-21
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 2023-09-26
D · Potential for more than minimal harm
2023-09-21
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-09-10
F · Potential for more than minimal harm
2021-12-01
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 2021-12-31
D · Potential for more than minimal harm
2021-12-01
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 2021-12-31
D · Potential for more than minimal harm
2021-12-01
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-12-31
D · Potential for more than minimal harm
2019-03-27
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 2019-05-04
D · Potential for more than minimal harm
2019-03-27
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 2019-05-04
D · Potential for more than minimal harm
2019-03-27
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2019-05-04
Penalties and ownership
What sits behind the stars
$12,149
2024-10-16
Fine
Fine · fine $12,149
Fine
$7,901
2023-09-21
Fine
Fine · fine $7,901
Fine
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
Love, Doyle
Operational/Managerial Control · Individual
Love, Doyle
W-2 Managing Employee · Individual
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · 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
Cumberland Health And Rehab
Bridgeport, AL
2-star overall rating with 1-star inspections with abuse icon flag with $238,745 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Dade Health And Rehab
Trenton, GA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare Of Monteagle Rehab & Wellness
Monteagle, TN
2-star overall rating with 2-star inspections with $39,507 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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