Cycle 1
Health 2025-12-17 · Fire 2025-12-17
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Harrogate, TN
Tri State Health And Rehabilitation Center
1-star overall rating with 1-star inspections with abuse icon flag with $14,852 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
600 Shawanee Rd, Harrogate, TN
(423) 869-5376
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1991-03-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
0.75
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,228
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.84
Baseline 22.48% · Performance 19.57% · Measure score 4.84 · Achievement 4.01 · Improvement 4.84
Healthcare-associated infections
1.36
Baseline 8.46% · Performance 7.81% · Measure score 1.36 · Achievement 0 · Improvement 1.36
Total nurse turnover
6.57
Baseline 49.28% · Performance 36.84% · Measure score 6.57 · Achievement 6.57 · Improvement 4.59
Adjusted total nurse staffing
0.67
Baseline 3.08 hours · Performance 3.27 hours · Measure score 0.67 · Achievement 0.67 · Improvement 0.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.61% |
10.72%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 19.55% · Lower 95% interval 10.68% |
| Discharge to community | 50.33% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 43.22% · Lower 95% interval 40.17% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.94% |
95.27%
2.3 pts worse
|
Numerator 79 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 60.61% |
53.69%
6.9 pts better
|
Numerator 40 · Denominator 66 |
| Discharge mobility score | 46.97% |
50.94%
4 pts worse
|
Numerator 31 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 1.18% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 85 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 8.33% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 142 |
| Staff flu vaccination coverage | 20.34% |
42%
21.7 pts worse
|
Numerator 36 · Denominator 177 |
| Discharge function score | 59.09% |
56.45%
2.6 pts better
|
Numerator 39 · Denominator 66 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.6
1.6 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.4 · Expected 1.8 · 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 | 100.0% |
94.5%
5.5 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 | 2.4% |
3.6%
1.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 4.4% · Q4 2.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
11.8%
5 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 7.4% · Q3 8.1% · Q4 10.6% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
6.2%
5.4 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.4% |
32.2%
4.2 pts worse
|
19.6%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 30.6% · Q3 39.0% · Q4 41.0% · 4Q avg 36.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
18.1%
1.4 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.4% · Q3 14.3% · Q4 14.3% · 4Q avg 16.7% · 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 | 30.9% |
19.9%
11 pts worse
|
16.3%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
15.3%
4.9 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 14.6% · Q3 9.5% · Q4 8.2% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · 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 2.5% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
20.2%
2.9 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 25.9% · Q3 30.3% · Q4 12.4% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.4%
2.1 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.5% · Q3 2.3% · Q4 4.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
79.6%
20.2 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
11.2%
7 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 16.9% · Expected 10.4% · 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 1.3% · Q2 1.2% · Q3 1.1% · Q4 2.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
22.2%
5 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 16.9% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
10 health deficiencies
Top issue: Administration (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-12-10 · Fire 2019-12-10
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-29
D · Potential for more than minimal harm
2023-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-16
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-16
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-09-12
F · Potential for more than minimal harm
2019-12-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-24
D · Potential for more than minimal harm
2025-12-17
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 2026-01-24
D · Potential for more than minimal harm
2025-12-17
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 2026-01-24
K · Immediate jeopardy
2024-09-26
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-10-19
K · Immediate jeopardy
2024-09-26
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 2024-10-19
K · Immediate jeopardy
2024-09-26
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-10-19
K · Immediate jeopardy
2024-09-26
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-10-19
K · Immediate jeopardy
2024-09-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-19
E · Potential for more than minimal harm
2024-09-26
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 2024-10-19
E · Potential for more than minimal harm
2024-09-26
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 2024-10-19
D · Potential for more than minimal harm
2024-09-26
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 2024-10-19
D · Potential for more than minimal harm
2023-08-16
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 2023-09-16
D · Potential for more than minimal harm
2023-08-16
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 2023-08-28
D · Potential for more than minimal harm
2019-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-12-10
Penalties and ownership
What sits behind the stars
$7,426
2024-09-26
Fine
Fine · fine $7,426
Fine
$7,426
2024-09-26
Fine
Fine · fine $7,426
Fine
Ownership
Rocky Top Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Abbott, Swati
Corporate Director · Individual
Agwunobi, John
Corporate Director · Individual
Albrechtsen, Tyler
Corporate Director · Individual
Blouin, Ann
Corporate Director · Individual
Burnam, Soon
Corporate Officer · Individual
Burton, Spencer
Corporate Officer · Individual
Christensen, Christopher
Corporate Director · Individual
Parkinson, Mark
Corporate Director · Individual
Port, Barry
Corporate Director · Individual
Port, Barry
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Shaw, Daren
Corporate Director · Individual
Smith, Barry
Corporate Director · Individual
Smith, Magen
Operational/Managerial Control · Individual
Snapper, Suzanne
Corporate Director · Individual
Snapper, Suzanne
Corporate Officer · Individual
Thatcher, Brent
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Middlesboro Nursing and Rehabilitation Facility
Middlesboro, KY
5-star overall rating with 5-star inspections
#2
Buchanan Place
New Tazewell, TN
2-star overall rating with 2-star inspections with $8,021 in total fines with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Claiborne Health And Rehabilitation Center
Tazewell, TN
4-star overall rating with 3-star inspections with 6 recent health deficiencies
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