Cycle 1
Health 2022-01-20 · Fire 2022-01-20
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waynesboro, TN
Waynesboro Post Acute & Rehabilitation
1-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies
104 J V Mangubat Drive, Waynesboro, TN
(931) 722-3641
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
109
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
2014-12-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 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
0.39
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,258
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.26
Baseline 16.43% · Performance 19.92% · Measure score 3.26 · Achievement 3.26 · Improvement 0
Healthcare-associated infections
1.77
Baseline 5.96% · Performance 7.31% · Measure score 1.77 · Achievement 1.77 · Improvement 0
Total nurse turnover
4.68
Baseline 93.75% · Performance 58.06% · Measure score 4.68 · Achievement 1.37 · Improvement 4.68
Adjusted total nurse staffing
0
Baseline 3.07 hours · Performance 2.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.12% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 18.07% · Lower 95% interval 9.31% |
| Discharge to community | 44.18% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 37.5% · Lower 95% interval 30.9% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 51 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 15 · Denominator 39 |
| Discharge mobility score | 25.64% |
50.94%
25.3 pts worse
|
Numerator 10 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 52 · Adjusted rate 3.39% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 68 |
| Staff flu vaccination coverage | 7.21% |
42%
34.8 pts worse
|
Numerator 8 · Denominator 111 |
| Discharge function score | 35.9% |
56.45%
20.6 pts worse
|
Numerator 14 · Denominator 39 |
| Transfer of health information to provider | 96.15% |
95.95%
0.2 pts better
|
Numerator 25 · Denominator 26 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · 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 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 41.8% |
89.9%
48.1 pts worse
|
93.4%
51.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 14.8% · Q3 14.9% · Q4 49.0% · 4Q avg 41.8% |
| 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 | 3.5% |
3.6%
0.1 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.7% · Q3 2.1% · Q4 4.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.9% |
11.8%
33.1 pts worse
|
11.4%
33.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 45.8% · Q3 36.4% · Q4 61.9% · 4Q avg 44.9% |
| Percentage of long-stay residents who lose too much weight | 11.9% |
6.2%
5.7 pts worse
|
5.4%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.9% · Q3 20.6% · Q4 11.4% · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.5% |
32.2%
8.3 pts worse
|
19.6%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 41.5% · Q3 44.4% · Q4 42.9% · 4Q avg 40.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.3% |
18.1%
6.2 pts worse
|
16.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 20.8% · Q3 22.2% · Q4 27.6% · 4Q avg 24.3% · 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 | 19.3% |
19.9%
0.6 pts better
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
15.3%
3.2 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 33.3% · Q3 0.0% · Q4 3.8% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 21.0% |
20.2%
0.8 pts worse
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 27.7% · Q3 14.2% · Q4 16.2% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
5.4%
5.1 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.0% |
79.6%
18.6 pts worse
|
81.7%
20.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 45.3% · Q3 46.4% · Q4 68.8% · 4Q avg 61.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
11.2%
3.3 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 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 | 35.4% |
79.8%
44.4 pts worse
|
79.7%
44.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
22.2%
4.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 23.4% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-15 · Fire 2019-05-15
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-06-27 · Fire 2018-06-27
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2018-06-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-07-22
C · Minimal harm
2018-06-27
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2018-07-22
C · Minimal harm
2018-06-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-07-22
C · Minimal harm
2018-06-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2018-07-22
C · Minimal harm
2018-06-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-07-22
Inspection history
Recent health citations
G · Actual harm
2025-10-22
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 2025-11-17
F · Potential for more than minimal harm
2025-10-22
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 2025-11-17
D · Potential for more than minimal harm
2025-10-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-10-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-17
E · Potential for more than minimal harm
2022-01-20
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 2022-02-14
D · Potential for more than minimal harm
2022-01-20
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 2022-02-14
D · Potential for more than minimal harm
2022-01-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-02-14
G · Actual harm
2018-06-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-07-27
G · Actual harm
2018-06-27
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 2018-07-27
G · Actual harm
2018-06-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-07-27
G · Actual harm
2018-06-27
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 2018-07-27
G · Actual harm
2018-06-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-07-27
G · Actual harm
2018-06-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-07-27
D · Potential for more than minimal harm
2018-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-07-27
D · Potential for more than minimal harm
2018-06-27
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2018-07-27
Penalties and ownership
What sits behind the stars
Ownership
Tn 2 SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bergin, Miles
Operational/Managerial Control · Individual
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Harbert Hills Academy N H
Savannah, TN
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Perry County Nursing Home
Linden, TN
1-star overall rating with 2-star inspections with $15,593 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Countryside Post-Acute And Rehabilitation Center
Lawrenceburg, TN
2-star overall rating with 2-star inspections with 9 recent health deficiencies
Jump out