3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Whites Creek, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
3425 Knight Drive, Whites Creek, TN
(615) 876-2754
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
127
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
1992-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 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
RN hours / resident day
0.36
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
81%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
9,896
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.93% · Performance 21.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.50
Baseline 8.45% · Performance 6.72% · Measure score 4.50 · Achievement 3.73 · Improvement 4.50
Total nurse turnover
4.34
Baseline 76.38% · Performance 51.43% · Measure score 4.34 · Achievement 3 · Improvement 4.34
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 11.69% · Lower 95% interval 7.09% |
| Discharge to community | 55.48% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 43.75% · Lower 95% interval 42.2% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 30.77% |
53.69%
22.9 pts worse
|
Numerator 8 · Denominator 26 |
| Discharge mobility score | 26.92% |
50.94%
24 pts worse
|
Numerator 7 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 6.98% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 1.57% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 127 |
| Staff flu vaccination coverage | 29.09% |
42%
12.9 pts worse
|
Numerator 32 · Denominator 110 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 12 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · 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 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
89.9%
7.4 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 92.5% · Q3 98.8% · Q4 100.0% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.5%
0.3 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 2.4% · Q4 2.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.1% |
11.8%
37.3 pts worse
|
11.4%
37.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 34.9% · Q3 68.7% · Q4 65.9% · 4Q avg 49.1% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.2%
0.2 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 14.1% · Q4 7.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
32.2%
16.6 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 14.3% · Q3 14.1% · Q4 17.9% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
18.1%
12.2 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.5% · Q3 6.1% · Q4 2.2% · 4Q avg 5.9% · 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 | 9.0% |
19.9%
10.9 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.4% · Q3 11.4% · Q4 0.0% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
15.3%
12.2 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.8% · Q3 3.1% · Q4 1.6% · 4Q avg 3.1% · 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 | 18.5% |
20.2%
1.7 pts better
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 27.2% · Q3 23.4% · Q4 12.0% · 4Q avg 18.5% |
| 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 3.8% · Q2 6.4% · Q3 8.3% · Q4 5.2% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
79.6%
17.5 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 95.1% · Q3 97.4% · Q4 100.0% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.2%
1.5 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 15.4% · Expected 13.6% · 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 | 94.7% |
79.8%
14.9 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.7% |
22.2%
4.5 pts better
|
23.9%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 19.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-27
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-04-27
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-04-27
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-04-27
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-04-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-04-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-04-27
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-04-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-04-27
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-04-27
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-04-27
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-02-28
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-02-28
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-02-28
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-02-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-02-28
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-02-28
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-05
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-05
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-05
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-19
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-09-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-09-02
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2021-09-02
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-04-27
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-04-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-03-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2018-03-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-03-20
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-03-20
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-03-20
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2018-03-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-03-20
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2018-03-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-03-20
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-03-20
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2018-03-20
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 2018-03-20
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-03-20
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2018-03-20
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2018-03-20
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 2018-03-20
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Security Interest · Organization
Nearby options
Nashville, TN
0-star overall rating with 0-star inspections with Special Focus status with $122,242 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Madison, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Nashville, TN
0-star overall rating with 0-star inspections with $125,508 in total fines
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