Cycle 1
Health 2019-10-24 · Fire 2019-10-24
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Oneonta, AL
Tlc Nursing Center
4-star overall rating with 4-star inspections with 4 fire-safety deficiencies in the latest cycle
212 Ellen Street, Oneonta, AL
(205) 625-3520
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trinity Management, Inc.
Operator or chain grouping
Approved since
1993-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 3 health / 4 staffing / 3 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
0.61
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,892
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.73% · Performance 23.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.55
Baseline 5.49% · Performance 6.78% · Measure score 3.55 · Achievement 3.55 · Improvement 0
Total nurse turnover
6.59
Baseline 34.34% · Performance 36.73% · Measure score 6.59 · Achievement 6.59 · Improvement 0
Adjusted total nurse staffing
3.74
Baseline 4 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 0.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.28% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 14.48% · Lower 95% interval 8.31% |
| Discharge to community | 52.58% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 47.15% · Lower 95% interval 44.13% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 102 · Denominator 102 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 102 |
| Discharge self-care score | 21.74% |
53.69%
31.9 pts worse
|
Numerator 20 · Denominator 92 |
| Discharge mobility score | 36.96% |
50.94%
14 pts worse
|
Numerator 34 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 102 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 5.56% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 155 |
| Staff flu vaccination coverage | 16.97% |
42%
25 pts worse
|
Numerator 28 · Denominator 165 |
| Discharge function score | 40.22% |
56.45%
16.2 pts worse
|
Numerator 37 · Denominator 92 |
| Transfer of health information to provider | 98.65% |
95.95%
2.7 pts better
|
Numerator 73 · Denominator 74 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.41% |
25.2%
20.8 pts worse
|
Numerator 3 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.3%
8.1 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.4%
1.4 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.0% · Q3 3.9% · Q4 3.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 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 | 2.7% |
5.3%
2.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · Q4 5.9% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
24.9%
4.9 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 22.7% · Q3 17.9% · Q4 14.5% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
22.8%
12.9 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.2% · Q3 13.2% · Q4 5.1% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 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 | 7.7% |
14.8%
7.1 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 4.9% · Q3 3.5% · Q4 8.5% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
13.4%
5.4 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 6.7% · Q3 1.6% · Q4 3.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 3.9% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.3% |
13.5%
5.2 pts better
|
19.8%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.9% · Q3 8.5% · Q4 10.3% · 4Q avg 8.3% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.7%
2.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.3% · Q3 2.6% · Q4 1.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
84.3%
11.7 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 92.5% · Q4 94.1% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
11.5%
4.2 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.1%
2.1 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 | 90.7% |
80.3%
10.4 pts better
|
79.7%
11 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
24.5%
4 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 26.7% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-09-13 · Fire 2018-09-13
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2017-08-10 · Fire 2017-08-10
10 health deficiencies
Top issue: Environmental (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-10-24
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-25
D · Potential for more than minimal harm
2017-08-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2017-08-28
D · Potential for more than minimal harm
2017-08-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2017-08-28
D · Potential for more than minimal harm
2017-08-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2017-08-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2018-09-13
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 2018-10-05
D · Potential for more than minimal harm
2018-09-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-09-19
D · Potential for more than minimal harm
2018-09-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-10-05
F · Potential for more than minimal harm
2017-08-10
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-09-01
F · Potential for more than minimal harm
2017-08-10
F372 · Environmental Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2017-09-01
E · Potential for more than minimal harm
2017-08-10
F428 · Pharmacy Service Deficiencies
Health
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F164 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F241 · Resident Rights Deficiencies
Health
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F323 · Environmental Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F333 · Pharmacy Service Deficiencies
Health
Ensure that residents are safe from serious medication errors.
Corrected 2017-09-01
D · Potential for more than minimal harm
2017-08-10
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-09-01
Penalties and ownership
What sits behind the stars
Ownership
Sims, Mark
5% Or Greater Direct Ownership Interest · Individual
Trintiy Management, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Quality Care Rehab Inc
Operational/Managerial Control · Organization
Sims, Mark
Corporate Director · Individual
Sims, Mark
Corporate Officer · Individual
Smith, John
Operational/Managerial Control · Individual
Trintiy Management, Inc.
Operational/Managerial Control · Organization
White, Madison
Operational/Managerial Control · Individual
Yeomans, Martin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Diversicare Of Oneonta
Oneonta, AL
2-star overall rating with 2-star inspections with $9,318 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Altoona Health & Rehab
Altoona, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Health Care Inc
Ashville, AL
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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