Cycle 1
Health 2022-03-02 · Fire 2022-03-02
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Westmoreland, TN
Westmoreland Care & Rehab Ctr
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1559 New Highway 52, Westmoreland, TN
(615) 644-5111
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1995-02-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 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
0.39
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,509
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.09% · Performance 25.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.60
Baseline 6.49% · Performance 7.36% · Measure score 1.60 · Achievement 1.60 · Improvement 0
Total nurse turnover
6.45
Baseline 45.45% · Performance 37.33% · Measure score 6.45 · Achievement 6.45 · Improvement 3.44
Adjusted total nurse staffing
0
Baseline 2.82 hours · Performance 2.74 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 110 · Observed rate 12.73% · Lower 95% interval 7.06% |
| Discharge to community | 52.06% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 42.16% · Lower 95% interval 41.07% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.88% |
95.27%
3.6 pts better
|
Numerator 88 · Denominator 89 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 89 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 34 · Denominator 58 |
| Discharge mobility score | 62.07% |
50.94%
11.1 pts better
|
Numerator 36 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.25% |
2.29%
About the same
|
Numerator 2 · Denominator 89 · Adjusted rate 2.31% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 13.71% |
42%
28.3 pts worse
|
Numerator 17 · Denominator 124 |
| Discharge function score | 67.24% |
56.45%
10.8 pts better
|
Numerator 39 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 16 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.6
1.2 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 1.9 · 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 | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 3.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
11.8%
3.2 pts better
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.4% · Q3 5.0% · Q4 3.3% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.2%
2.9 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 3.6% · Q4 3.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
32.2%
2.6 pts better
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 28.3% · Q3 30.4% · Q4 35.0% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
18.1%
9.2 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.9% · Q3 4.7% · Q4 11.6% · 4Q avg 8.9% · 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 | 10.6% |
19.9%
9.3 pts better
|
16.3%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · 4Q avg 10.6% · 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 8.3% · Q2 14.3% · Q3 5.8% · Q4 13.0% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · 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 | 21.1% |
20.2%
0.9 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 22.4% · Q3 22.7% · Q4 14.3% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.4%
2.4 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 15.1% · Q3 5.6% · Q4 2.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
79.6%
18.6 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.9% · Q3 97.9% · Q4 99.2% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.2%
3.4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.6%
0.6 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
79.8%
18.1 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.2%
1.5 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 23.8% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-08 · Fire 2019-05-08
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-05-10 · Fire 2018-05-10
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 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
2022-03-02
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 2022-03-14
D · Potential for more than minimal harm
2019-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-05-08
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 2019-06-10
D · Potential for more than minimal harm
2019-05-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-06-10
D · Potential for more than minimal harm
2018-05-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-03-02
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 2022-03-31
E · Potential for more than minimal harm
2022-03-02
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 2022-03-31
D · Potential for more than minimal harm
2022-03-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-03-02
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 2022-03-31
D · Potential for more than minimal harm
2022-03-02
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 2022-03-31
D · Potential for more than minimal harm
2022-03-02
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 2022-03-31
D · Potential for more than minimal harm
2022-03-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-31
D · Potential for more than minimal harm
2022-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-31
F · Potential for more than minimal harm
2018-05-10
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 2018-06-04
D · Potential for more than minimal harm
2018-05-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-06-04
Penalties and ownership
What sits behind the stars
Ownership
Lp Cr Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Agemo Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Spears, Lashell
Operational/Managerial Control · Individual
Spears, Lashell
W-2 Managing Employee · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Hartsville Convalescent Center
Hartsville, TN
2-star overall rating with 2-star inspections with $16,796 in total fines with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Knollwood Manor
Lafayette, TN
1-star overall rating with 1-star inspections with 5 recent health deficiencies
#3
Signature Health Of Portland Rehab & Wellness Cent
Portland, TN
1-star overall rating with 1-star inspections with abuse icon flag with $107,228 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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