Cycle 1
Health 2025-01-23 · Fire 2025-01-23
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lafollette, TN
Tennova Lafollette Health And Rehab Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies
200 Torrey Road, Lafollette, TN
(423) 907-1380
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-12-15
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.70
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
1.04
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
94%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
98%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,104
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.65% · Performance 21.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.70
Baseline 6.58% · Performance 7.62% · Measure score 0.70 · Achievement 0.70 · Improvement 0
Total nurse turnover
1.46
Baseline 31.25% · Performance 57.69% · Measure score 1.46 · Achievement 1.46 · Improvement 0
Adjusted total nurse staffing
1.17
Baseline 3.75 hours · Performance 3.41 hours · Measure score 1.17 · Achievement 1.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.22% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 11.63% · Lower 95% interval 7.64% |
| Discharge to community | 57.27% |
50.57%
6.7 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 52.5% · Lower 95% interval 45.12% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 50 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 78.05% |
53.69%
24.4 pts better
|
Numerator 32 · Denominator 41 |
| Discharge mobility score | 73.17% |
50.94%
22.2 pts better
|
Numerator 30 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.92% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 52 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 7.62% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 89 |
| Staff flu vaccination coverage | 46.24% |
42%
4.2 pts better
|
Numerator 43 · Denominator 93 |
| Discharge function score | 80.49% |
56.45%
24 pts better
|
Numerator 33 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
89.9%
8 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 100.0% · Q3 98.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.5%
3.6 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.2% · Q3 6.1% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 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 who lose too much weight | 11.3% |
6.2%
5.1 pts worse
|
5.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.5% · Q3 13.0% · Q4 14.6% · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 44.9% |
32.2%
12.7 pts worse
|
19.6%
25.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 43.8% · Q3 43.5% · Q4 47.9% · 4Q avg 44.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.3% |
18.1%
15.2 pts worse
|
16.7%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 31.0% · Q3 38.6% · Q4 34.1% · 4Q avg 33.3% · 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 | 16.7% |
19.9%
3.2 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 18.7% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
15.3%
2.1 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 7.7% · Q3 15.4% · Q4 13.2% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 3.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.9%
0.9 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
20.2%
3.4 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 13.0% · Q3 9.3% · Q4 21.1% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.4%
0.9 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.1% · Q3 2.1% · Q4 5.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
79.6%
17.9 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 100.0% · Q3 100.0% · Q4 95.8% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.6% |
11.2%
18.4 pts worse
|
12.0%
17.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 27.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.6%
0.1 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
79.8%
12.4 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
22.2%
5.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 24.1% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-06 · Fire 2022-04-06
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-01-23 · Fire 2020-01-23
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2020-01-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-28
F · Potential for more than minimal harm
2020-01-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-23
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 2020-02-29
C · Minimal harm
2020-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-23
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 2025-02-28
D · Potential for more than minimal harm
2024-11-04
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 2024-12-06
D · Potential for more than minimal harm
2024-11-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-04
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
F · Potential for more than minimal harm
2022-04-06
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 2022-05-21
D · Potential for more than minimal harm
2022-04-06
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 2022-05-21
D · Potential for more than minimal harm
2022-04-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-05-21
D · Potential for more than minimal harm
2022-04-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-21
D · Potential for more than minimal harm
2022-04-06
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-05-21
D · Potential for more than minimal harm
2022-04-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-05-21
D · Potential for more than minimal harm
2022-04-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-05-21
E · Potential for more than minimal harm
2020-01-23
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 2020-02-10
D · Potential for more than minimal harm
2020-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-10
D · Potential for more than minimal harm
2020-01-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-02-10
D · Potential for more than minimal harm
2020-01-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-01-30
D · Potential for more than minimal harm
2020-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-30
Penalties and ownership
What sits behind the stars
Ownership
Health Management Associates LLC
5% Or Greater Direct Ownership Interest · Organization
Buffington-Price, Edna
Corporate Director · Individual
Cash, William
Corporate Officer · Individual
Chs Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Cobb, Christopher
Corporate Officer · Individual
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Dhandapani, Murugesen
Operational/Managerial Control · Individual
Hammons, Kevin
Corporate Director · Individual
Hammons, Kevin
Corporate Officer · Individual
Hma-Tri Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Johnson, Jason
Corporate Officer · Individual
Lalor, Paula
Corporate Director · Individual
Lawson, Lindsey
Operational/Managerial Control · Individual
Ottinger, Roman
Corporate Officer · Individual
Pitt, Justin
Corporate Director · Individual
Pitt, Justin
Corporate Officer · Individual
Summar, Nathaniel
Corporate Director · Individual
Williams, Donald
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cumberland Village Care
Lafollette, TN
4-star overall rating with 4-star inspections with $18,769 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Rocky Top Care Center
Rocky Top, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $86,768 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Andersonville Tn Opco LLC
Andersonville, TN
2-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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