Cycle 1
Health 2024-02-22 · Fire 2024-02-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pleasant Hill, TN
Wharton Nursing Home
1-star overall rating with 1-star inspections with $78,533 in total fines with 5 recent health deficiencies
878-880 West Main Street, Pleasant Hill, TN
(931) 277-3511
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-09-19
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
0.31
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.65
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.66
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
3,426
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.90
Baseline 17.73% · Performance 19.62% · Measure score 3.90 · Achievement 3.90 · Improvement 0
Healthcare-associated infections
5.87
Baseline 6.19% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 0.42
Total nurse turnover
1.70
Baseline 58.21% · Performance 56.72% · Measure score 1.70 · Achievement 1.70 · Improvement 0
Adjusted total nurse staffing
6.28
Baseline 3.42 hours · Performance 4.87 hours · Measure score 6.28 · Achievement 6.28 · Improvement 5.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 8.24% · Lower 95% interval 7.61% |
| Discharge to community | 63.44% |
50.57%
12.9 pts better
|
Better than the National Rate · Eligible stays 285 · Observed rate 61.75% · Lower 95% interval 57.95% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 106 · Denominator 107 |
| Falls with major injury | 1.87% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 107 |
| Discharge self-care score | 54.84% |
53.69%
1.2 pts better
|
Numerator 51 · Denominator 93 |
| Discharge mobility score | 65.59% |
50.94%
14.7 pts better
|
Numerator 61 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 1.87% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 107 · Adjusted rate 2.34% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 4.05% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 3.08% |
8.2%
5.1 pts worse
|
Numerator 2 · Denominator 65 |
| Staff flu vaccination coverage | 54.46% |
42%
12.5 pts better
|
Numerator 55 · Denominator 101 |
| Discharge function score | 62.37% |
56.45%
5.9 pts better
|
Numerator 58 · Denominator 93 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 83 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 47.92% |
25.2%
22.7 pts better
|
Numerator 23 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.6
1.8 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.5% |
89.9%
16.4 pts worse
|
93.4%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 74.1% · Q3 70.4% · Q4 72.7% · 4Q avg 73.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
94.5%
7 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.1% · Q3 0.0% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
11.8%
9.9 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
6.2%
5.2 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
32.2%
8 pts better
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 21.7% · Q3 25.0% · Q4 23.1% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.9% |
18.1%
14.8 pts worse
|
16.7%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.9% · 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 · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
15.3%
4 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 35.0% · Q3 9.5% · Q4 4.2% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 4.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.9%
1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
20.2%
11.6 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 41.1% · Q3 31.2% · Q4 27.3% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.4%
2.5 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 10.7% · Q3 4.6% · Q4 8.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
79.6%
10.2 pts worse
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 86.3% · Q3 63.9% · Q4 47.1% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
11.2%
0.7 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 9.6% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.6%
0.9 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
79.8%
5.8 pts better
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
22.2%
1.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 17.3% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-30 · Fire 2021-06-30
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-02-12 · Fire 2019-02-12
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-06-30
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-06-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-06-28
D · Potential for more than minimal harm
2019-02-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-08
Inspection history
Recent health citations
J · Immediate jeopardy
2024-05-24
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 2024-05-25
J · Immediate jeopardy
2024-05-24
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 2024-05-25
J · Immediate jeopardy
2024-05-24
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 2024-05-25
G · Actual harm
2024-02-22
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 2024-03-04
F · Potential for more than minimal harm
2024-02-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-22
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 2024-03-08
D · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-05
G · Actual harm
2023-06-06
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 2023-07-30
G · Actual harm
2023-06-06
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 2023-07-30
D · Potential for more than minimal harm
2021-06-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-06-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-06-30
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 2021-07-07
D · Potential for more than minimal harm
2019-02-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
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 2019-03-08
D · Potential for more than minimal harm
2019-02-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
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 2019-03-08
D · Potential for more than minimal harm
2019-02-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-08
Penalties and ownership
What sits behind the stars
$30,722
2024-05-24
Fine
Fine · fine $30,722
Fine
$39,163
2024-02-22
Fine
Fine · fine $39,163
Fine
$8,648
2023-06-06
Fine
Fine · fine $8,648
Fine
$0
2023-06-06
Payment Denial
Payment Denial · denial start 2023-07-06 · 24 days
24 day denial
Ownership
Chitiyo, George
Corporate Director · Individual
Clemow, Derrick
Corporate Director · Individual
Everett, Barbara
Corporate Director · Individual
Hanson, Holly
Corporate Director · Individual
Mitchell, Tom
Corporate Director · Individual
Murner, Herschel
Operational/Managerial Control · Individual
Murner, Herschel
Corporate Director · Individual
Murner, Herschel
Corporate Officer · Individual
Murner, Herschel
Contracted Managing Employee · Individual
Murner, Herschel
W-2 Managing Employee · Individual
Overlock, Marc
Corporate Director · Individual
Peeples, Susan
Corporate Director · Individual
Smith, Barbara
Corporate Director · Individual
Smith, Cynthia
Contracted Managing Employee · Individual
Smith, Cynthia
W-2 Managing Employee · Individual
Uplands Village
5% Or Greater Direct Ownership Interest · Organization
Nearby options
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#2
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3-star overall rating with 4-star inspections with 3 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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