Cycle 1
Health 2020-02-26 · Fire 2020-02-26
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Smyrna, TN
Smyrna Care Center
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
200 Mayfield Drive, Smyrna, TN
(615) 355-0350
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Exceptional Living Centers
Operator or chain grouping
Approved since
1983-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 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
0.71
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.06
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
3.89
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,305
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.26
Baseline 21.46% · Performance 19.46% · Measure score 4.26 · Achievement 4.26 · Improvement 4.01
Healthcare-associated infections
0
Baseline 6.24% · Performance 7.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.13
Baseline 66.34% · Performance 63.73% · Measure score 0.13 · Achievement 0 · Improvement 0.13
Adjusted total nurse staffing
2.54
Baseline 4.32 hours · Performance 3.8 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 7.25% · Lower 95% interval 6.47% |
| Discharge to community | 57.08% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 48% · Lower 95% interval 43.01% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.88% |
95.27%
1.4 pts worse
|
Numerator 46 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 53.57% |
53.69%
0.1 pts worse
|
Numerator 15 · Denominator 28 |
| Discharge mobility score | 39.29% |
50.94%
11.6 pts worse
|
Numerator 11 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 8.16% |
2.29%
5.9 pts worse
|
Numerator 4 · Denominator 49 · Adjusted rate 6.31% |
| Healthcare-associated infections requiring hospitalization | 7.79% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 12.5% · Lower 95% interval 5.49% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 39.29% |
56.45%
17.2 pts worse
|
Numerator 11 · Denominator 28 |
| Transfer of health information to provider | 61.9% |
95.95%
34.1 pts worse
|
Numerator 13 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 5 · Denominator 29 |
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 1.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.7% |
89.9%
11.2 pts worse
|
93.4%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 74.0% · Q3 84.0% · Q4 88.1% · 4Q avg 78.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
94.5%
1.6 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.6%
2.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
11.8%
6.7 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.1% · Q3 6.9% · Q4 5.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
6.2%
4.2 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.3% · Q3 1.6% · Q4 1.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.7% |
32.2%
1.5 pts better
|
19.6%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 34.4% · Q3 29.7% · Q4 21.3% · 4Q avg 30.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
18.1%
5.2 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 13.6% · Q3 12.2% · Q4 14.0% · 4Q avg 12.9% · 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 | 23.6% |
19.9%
3.7 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 23.9% · Q4 21.2% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
15.3%
5 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 21.1% · Q3 32.8% · Q4 17.6% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.1% · Q3 1.0% · Q4 1.0% · 4Q avg 1.1% · 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 3.7% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.6% |
20.2%
15.4 pts worse
|
19.8%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 32.6% · Q3 39.4% · Q4 36.9% · 4Q avg 35.6% |
| 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 5.2% · Q2 5.8% · Q3 7.3% · Q4 2.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.2% |
79.6%
41.4 pts worse
|
81.7%
43.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.5% · Q2 39.2% · Q3 29.8% · Q4 41.6% · 4Q avg 38.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
11.2%
2.5 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 17.0% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.6%
1.1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.9% |
79.8%
37.9 pts worse
|
79.7%
37.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
22.2%
0.9 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 26.4% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-03-06 · Fire 2019-03-06
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2018-01-24 · Fire 2018-01-24
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-04
F · Potential for more than minimal harm
2020-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-17
F · Potential for more than minimal harm
2020-02-26
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-04-11
F · Potential for more than minimal harm
2020-02-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-04-09
E · Potential for more than minimal harm
2020-02-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-04-09
D · Potential for more than minimal harm
2020-02-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-03-17
D · Potential for more than minimal harm
2020-02-26
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 2020-03-04
D · Potential for more than minimal harm
2020-02-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-02-26
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 2020-02-27
D · Potential for more than minimal harm
2020-02-26
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-02-24
D · Potential for more than minimal harm
2019-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-04-10
D · Potential for more than minimal harm
2019-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-04-10
D · Potential for more than minimal harm
2019-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-10
D · Potential for more than minimal harm
2018-01-24
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 2018-02-05
D · Potential for more than minimal harm
2018-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-02-05
D · Potential for more than minimal harm
2018-01-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-02-05
D · Potential for more than minimal harm
2018-01-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-02-05
D · Potential for more than minimal harm
2018-01-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-02-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2020-02-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2020-03-20
F · Potential for more than minimal harm
2020-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-26
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 2020-03-20
D · Potential for more than minimal harm
2020-02-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-26
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 2020-03-20
D · Potential for more than minimal harm
2020-02-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-26
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 2020-03-20
D · Potential for more than minimal harm
2020-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-20
F · Potential for more than minimal harm
2019-03-06
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 2019-04-10
F · Potential for more than minimal harm
2019-03-06
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 2019-04-10
E · Potential for more than minimal harm
2019-03-06
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 2019-04-10
D · Potential for more than minimal harm
2019-03-06
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 2019-04-10
D · Potential for more than minimal harm
2019-03-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-04-10
D · Potential for more than minimal harm
2019-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-04-10
D · Potential for more than minimal harm
2019-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-04-10
G · Actual harm
2018-01-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-02-12
G · Actual harm
2018-01-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-02-12
G · Actual harm
2018-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-02-12
G · Actual harm
2018-01-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-02-12
G · Actual harm
2018-01-24
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 2018-02-12
F · Potential for more than minimal harm
2018-01-24
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 2018-02-12
D · Potential for more than minimal harm
2018-01-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-02-12
D · Potential for more than minimal harm
2018-01-24
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 2018-02-12
D · Potential for more than minimal harm
2018-01-24
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 2018-02-12
D · Potential for more than minimal harm
2018-01-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-02-12
D · Potential for more than minimal harm
2018-01-24
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 2018-02-12
D · Potential for more than minimal harm
2018-01-24
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 2018-02-12
D · Potential for more than minimal harm
2018-01-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2018-02-12
Penalties and ownership
What sits behind the stars
Ownership
Medical Rehabilitation Centers, LLC
5% Or Greater Direct Ownership Interest · Organization
Campbell, Brenda
Operational/Managerial Control · Individual
Lexington Health Management LLC
5% Or Greater Indirect Ownership Interest · Organization
Park, Seleena
Operational/Managerial Control · Individual
Watts, Amy
5% Or Greater Indirect Ownership Interest · Individual
Watts, Walter
5% Or Greater Indirect Ownership Interest · Individual
Watts, Walter
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Waters Of Smyrna, LLC
Smyrna, TN
1-star overall rating with 1-star inspections with $104,124 in total fines with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Hickory Woods
Antioch, TN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Tennessee Veterans Home
Murfreesboro, TN
1-star overall rating with 1-star inspections with abuse icon flag with $193,155 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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