Cycle 1
Health 2025-09-11 · Fire 2025-09-11
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Germantown, TN
The Village At Germantown
2-star overall rating with 1-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7930 Walking Horse Circle, Germantown, TN
(901) 752-2580
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-07-21
CMS approved date
Coverage
Medicare
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
1.06
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.79
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
3.94
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
6.79
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.85
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
5.75
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
6.09
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,416
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.49% · Performance 26.54% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.07
Baseline 6.38% · Performance 7.22% · Measure score 2.07 · Achievement 2.07 · Improvement 0
Total nurse turnover
3.96
Baseline 78.87% · Performance 54.76% · Measure score 3.96 · Achievement 2.18 · Improvement 3.96
Adjusted total nurse staffing
10
Baseline 5.52 hours · Performance 6.32 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.81% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 461 · Observed rate 11.28% · Lower 95% interval 10.42% |
| Discharge to community | 63.21% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 512 · Observed rate 60.94% · Lower 95% interval 57.98% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.03% |
95.27%
2.8 pts better
|
Numerator 299 · Denominator 305 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 3 · Denominator 305 |
| Discharge self-care score | 67.59% |
53.69%
13.9 pts better
|
Numerator 146 · Denominator 216 |
| Discharge mobility score | 35.65% |
50.94%
15.3 pts worse
|
Numerator 77 · Denominator 216 |
| Pressure ulcers or injuries, new or worsened | 1.31% |
2.29%
1 pts better
|
Numerator 4 · Denominator 305 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 272 · Observed rate 6.25% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 1.79% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 56 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 46.76% |
56.45%
9.7 pts worse
|
Numerator 101 · Denominator 216 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 82 · Denominator 84 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 199 · Denominator 199 |
| Resident COVID-19 vaccinations up to date | 19.75% |
25.2%
5.4 pts worse
|
Numerator 32 · Denominator 162 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
94.5%
3.6 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.3% |
11.8%
10.5 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 4.8% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.2%
1.6 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.8% |
32.2%
1.6 pts worse
|
19.6%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
18.1%
8.8 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · 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 need for help with daily activities has increased | 21.7% |
15.3%
6.4 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.6% |
1.9%
6.7 pts worse
|
1.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 15.0% · Q4 0.0% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
20.2%
5.1 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 27.7% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
5.4%
5.4 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 8.2% · Q4 15.5% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
79.6%
18 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.4% · Q3 96.5% · Q4 96.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
11.2%
1.3 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 10.9% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.6%
0.7 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.7% · Q3 3.4% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.7% |
79.8%
13.9 pts better
|
79.7%
14 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.0% |
22.2%
9.8 pts worse
|
23.9%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.0% · Observed 25.9% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-22 · Fire 2022-09-22
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-14 · Fire 2019-08-14
5 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-11
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 2025-11-04
D · Potential for more than minimal harm
2025-09-11
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-11-04
D · Potential for more than minimal harm
2025-09-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-04
D · Potential for more than minimal harm
2019-08-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-09-27
D · Potential for more than minimal harm
2019-08-14
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 2019-08-22
D · Potential for more than minimal harm
2019-08-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-28
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-09-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-26
E · Potential for more than minimal harm
2025-09-11
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 2025-09-12
D · Potential for more than minimal harm
2025-09-11
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 2025-09-22
D · Potential for more than minimal harm
2025-09-11
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 2025-11-21
G · Actual harm
2022-09-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-22
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 2022-10-17
D · Potential for more than minimal harm
2022-09-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-17
F · Potential for more than minimal harm
2019-08-14
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 2019-09-17
D · Potential for more than minimal harm
2019-08-14
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-09-17
D · Potential for more than minimal harm
2019-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-17
Penalties and ownership
What sits behind the stars
Ownership
Lavy, Junaita
Operational/Managerial Control · Individual
Repking, Julie
Operational/Managerial Control · Individual
Selheimer, Donald
Operational/Managerial Control · Individual
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