Cycle 1
Health 2025-05-07 · Fire 2025-05-07
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Jackson, TN
West Tennessee Post Acute
3-star overall rating with 3-star inspections with 7 recent health deficiencies
597 West Forest Avenue, Jackson, TN
(731) 300-4800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
67
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
1986-03-06
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
2.01
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.29
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.94
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.38
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,395
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0040
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.47
Baseline 21.55% · Performance 19.36% · Measure score 4.47 · Achievement 4.47 · Improvement 4.34
Healthcare-associated infections
5.04
Baseline 7.93% · Performance 6.33% · Measure score 5.04 · Achievement 5.04 · Improvement 4.96
Total nurse turnover
5.92
Baseline 40.28% · Performance 39.47% · Measure score 5.92 · Achievement 5.92 · Improvement 0.02
Adjusted total nurse staffing
4.56
Baseline 4.13 hours · Performance 4.38 hours · Measure score 4.56 · Achievement 4.56 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 460 · Observed rate 10.22% · Lower 95% interval 7.78% |
| Discharge to community | 55.76% |
50.57%
5.2 pts better
|
Better than the National Rate · Eligible stays 518 · Observed rate 46.72% · Lower 95% interval 50.7% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 330 · Denominator 335 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 335 |
| Discharge self-care score | 51.43% |
53.69%
2.3 pts worse
|
Numerator 108 · Denominator 210 |
| Discharge mobility score | 58.1% |
50.94%
7.2 pts better
|
Numerator 122 · Denominator 210 |
| Pressure ulcers or injuries, new or worsened | 4.48% |
2.29%
2.2 pts worse
|
Numerator 15 · Denominator 335 · Adjusted rate 4.47% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 315 · Observed rate 6.03% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 3.16% |
8.2%
5 pts worse
|
Numerator 5 · Denominator 158 |
| Staff flu vaccination coverage | 47.13% |
42%
5.1 pts better
|
Numerator 74 · Denominator 157 |
| Discharge function score | 62.38% |
56.45%
5.9 pts better
|
Numerator 131 · Denominator 210 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 225 · Denominator 225 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 105 · Denominator 110 |
| Resident COVID-19 vaccinations up to date | 6.82% |
25.2%
18.4 pts worse
|
Numerator 12 · Denominator 176 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
79.6%
18.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 98.3% · Q3 99.4% · Q4 99.1% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
11.2%
2.5 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 12.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.6%
0.2 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.1% · Q3 1.2% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
79.8%
17.1 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
22.2%
3.6 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 25.9% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-17
D · Potential for more than minimal harm
2023-07-13
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 2023-07-27
D · Potential for more than minimal harm
2023-07-13
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-07-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-07
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 2025-05-31
D · Potential for more than minimal harm
2025-05-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-07
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 2025-05-31
D · Potential for more than minimal harm
2025-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-31
D · Potential for more than minimal harm
2024-06-20
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 2024-07-03
D · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-03
E · Potential for more than minimal harm
2023-07-13
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 2023-07-26
E · Potential for more than minimal harm
2023-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-07-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-07-13
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 2023-07-26
D · Potential for more than minimal harm
2023-07-13
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-26
Penalties and ownership
What sits behind the stars
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
597 West Forest Avenue Tn LLC
5% Or Greater Mortgage Interest · Organization
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Reyes, Ronald
Operational/Managerial Control · Individual
Rodriguez, Curtis
Operational/Managerial Control · Individual
Rodriguez, Curtis
Corporate Officer · Individual
Tilford, Toby
Operational/Managerial Control · Individual
Tilford, Toby
Corporate Officer · Individual
Webb, Bradley
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cypress Grove Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with $17,355 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Mission Convalescent Home
Jackson, TN
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Laurelwood Health Care Center
Jackson, TN
2-star overall rating with 2-star inspections with $126,516 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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