Cycle 1
Health 2025-09-04 · Fire 2025-09-04
6 health deficiencies
Top issue: Administration (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Winchester, TN
Southern Tenn Medical Center SNF
3-star overall rating with 2-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
629 Hospital Road, Winchester, TN
(931) 967-8249
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
17
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-04-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
2.40
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
3.07
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
7.73
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
5.46
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
6.57
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.56
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.38
CMS adjusted RN staffing hours
Adjusted total hours
7.67
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,029
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9997
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.12
Baseline 18.66% · Performance 19.52% · Measure score 4.12 · Achievement 4.12 · Improvement 0
Healthcare-associated infections
2.88
Baseline 5.33% · Performance 6.97% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Total nurse turnover
6.90
Performance 35.48% · Measure score 6.90 · Achievement 6.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 10.18% · Lower 95% interval 7.9% |
| Discharge to community | 70.52% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 153 · Observed rate 67.97% · Lower 95% interval 61.97% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.2% |
95.27%
8.1 pts worse
|
Numerator 109 · Denominator 125 |
| Falls with major injury | 0.8% |
0.77%
About the same
|
Numerator 1 · Denominator 125 |
| Discharge self-care score | 63.38% |
53.69%
9.7 pts better
|
Numerator 45 · Denominator 71 |
| Discharge mobility score | 69.01% |
50.94%
18.1 pts better
|
Numerator 49 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 0.8% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 125 · Adjusted rate 0.96% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 37 |
| Staff flu vaccination coverage | 67.53% |
42%
25.5 pts better
|
Numerator 52 · Denominator 77 |
| Discharge function score | 73.24% |
56.45%
16.8 pts better
|
Numerator 52 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 74 · Denominator 74 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 11.67% |
25.2%
13.5 pts worse
|
Numerator 7 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
79.6%
8.5 pts better
|
81.7%
6.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 83.3% · Q3 93.3% · Q4 93.6% · 4Q avg 88.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.0% |
11.2%
11.8 pts worse
|
12.0%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 22.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.4% |
79.8%
0.4 pts worse
|
79.7%
0.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
22.2%
3.1 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 17.3% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-13 · Fire 2022-07-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-08 · Fire 2019-05-08
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-19
D · Potential for more than minimal harm
2022-07-13
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 2022-07-15
D · Potential for more than minimal harm
2019-05-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-10-19
F · Potential for more than minimal harm
2025-09-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-10-19
E · Potential for more than minimal harm
2025-09-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-19
E · Potential for more than minimal harm
2025-09-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-10-19
E · Potential for more than minimal harm
2025-09-04
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-10-19
D · Potential for more than minimal harm
2025-09-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-19
F · Potential for more than minimal harm
2022-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-25
E · Potential for more than minimal harm
2022-07-13
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 2022-08-25
D · Potential for more than minimal harm
2022-07-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-25
B · Minimal harm
2022-07-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-25
D · Potential for more than minimal harm
2019-05-08
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 2019-05-29
Penalties and ownership
What sits behind the stars
Ownership
Highpoint Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Ascension Health
5% Or Greater Indirect Ownership Interest · Organization
Baptist Health Care Affiliates Inc
5% Or Greater Indirect Ownership Interest · Organization
Davis, Daniel
Corporate Officer · Individual
Dsb Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Edwards, Danny
Operational/Managerial Control · Individual
Grooms, John
Corporate Officer · Individual
Haugh, William
Corporate Officer · Individual
Highpoint Partner, LLC
5% Or Greater Indirect Ownership Interest · Organization
Historic Lifepoint Hospitals, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lawrence, Charlotte
Corporate Officer · Individual
Legacy Lifepoint Health LLC
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Corporate Services General Partnership
General Partnership Interest · Organization
Lifepoint Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Holdings 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Hospitals Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Martin, Adam
Operational/Managerial Control · Individual
Monte, Christopher
Corporate Officer · Individual
Poppell, Marcus
Corporate Officer · Individual
Saint Thomas Health
5% Or Greater Indirect Ownership Interest · Organization
Saint Thomas Network
5% Or Greater Indirect Ownership Interest · Organization
Selbe, Jamie
Operational/Managerial Control · Individual
Wofford, Jody
Operational/Managerial Control · Individual
Zaharcu, Alexandru
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Elk River Health & Nursing Center Of Winchester
Winchester, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
The Waters Of Winchester, LLC
Winchester, TN
4-star overall rating with 5-star inspections with $19,325 in total fines with 1 recent health deficiencies with 19 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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