Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Knoxville, TN
West Hills Health And Rehab
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
6801 Middlebrook Pike, Knoxville, TN
(865) 588-7661
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
194
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2011-01-20
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
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.91
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
3.56
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,161
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.28
Baseline 20.01% · Performance 18.06% · Measure score 7.28 · Achievement 7.28 · Improvement 6.05
Healthcare-associated infections
0
Baseline 6.06% · Performance 7.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.01
Baseline 3.58 hours · Performance 3.36 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 11.24% · Lower 95% interval 7.49% |
| Discharge to community | 50.55% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 132 · Observed rate 42.42% · Lower 95% interval 41.22% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 95 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 27.4% |
53.69%
26.3 pts worse
|
Numerator 20 · Denominator 73 |
| Discharge mobility score | 10.96% |
50.94%
40 pts worse
|
Numerator 8 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 100 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 7.7% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 8.14% · Lower 95% interval 4.69% |
| Staff COVID-19 vaccination coverage | 2.15% |
8.2%
6 pts worse
|
Numerator 2 · Denominator 93 |
| Staff flu vaccination coverage | 51.72% |
42%
9.7 pts better
|
Numerator 30 · Denominator 58 |
| Discharge function score | 31.51% |
56.45%
24.9 pts worse
|
Numerator 23 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 38 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 6.56% |
25.2%
18.6 pts worse
|
Numerator 4 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 3.2 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
89.9%
7.6 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 90.4% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 65.1% |
94.5%
29.4 pts worse
|
95.5%
30.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 65.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.6%
1.4 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.6% · Q4 1.2% · 4Q avg 2.2% · 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 | 3.7% |
6.2%
2.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 5.1% · Q4 6.2% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
32.2%
16.9 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 14.3% · Q3 16.1% · Q4 15.7% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
18.1%
9.6 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.1% · Q3 6.4% · Q4 11.1% · 4Q avg 8.5% · 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 | 39.3% |
19.9%
19.4 pts worse
|
16.3%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
15.3%
10.8 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 21.8% · Q3 29.6% · Q4 25.9% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.2% · Q3 4.1% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.9%
0.4 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 1.3% · Q4 5.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
20.2%
11.3 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 36.2% · Q3 31.1% · Q4 25.6% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.4%
0.4 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 7.5% · Q3 4.5% · Q4 4.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
79.6%
15.9 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 95.9% · Q3 98.5% · Q4 91.8% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.2%
2 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 9.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.6%
0.8 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.2% · Q3 3.3% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 18.9% |
79.8%
60.9 pts worse
|
79.7%
60.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 18.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
22.2%
2.3 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 20.4% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-02 · Fire 2022-02-02
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-03-20 · Fire 2019-03-20
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-16
D · Potential for more than minimal harm
2022-02-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-05
D · Potential for more than minimal harm
2022-02-02
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-03-05
F · Potential for more than minimal harm
2019-03-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-03-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-03-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-04
D · Potential for more than minimal harm
2024-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-04
D · Potential for more than minimal harm
2022-02-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-05
G · Actual harm
2019-03-20
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 2019-03-22
G · Actual harm
2019-03-20
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 2019-03-22
D · Potential for more than minimal harm
2019-03-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-20
D · Potential for more than minimal harm
2019-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-05
Penalties and ownership
What sits behind the stars
Ownership
Hillcrest Healthcare Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Bowers, Jonathan
W-2 Managing Employee · Individual
Dibernardo, Bruce
W-2 Managing Employee · Individual
Home Federal Bank Of Tennessee
5% Or Greater Mortgage Interest · Organization
Lepley, Bonnie
W-2 Managing Employee · Individual
Whitlock, Kevin
Corporate Director · Individual
Whitlock, Kevin
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Legacy Park Health And Rehabilitation
Knoxville, TN
1-star overall rating with 2-star inspections with $184,672 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Wellpark At Shannondale
Knoxville, TN
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Lyonsview Health And Rehabilitation Center
Knoxville, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $99,788 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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