Whites Creek, TN

Whites Creek Wellness And Rehabilitation Center

4-star overall rating with 4-star inspections with 3 recent health deficiencies

3425 Knight Drive, Whites Creek, TN

(615) 876-2754

Compare this facility

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

Facility snapshot

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

Hours and turnover

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

Value-based purchasing

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

How the VBP score is built

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

Medicare quality reporting measures

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

Resident outcomes and process scores

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

Recent inspection cycles

Cycle 1 Health 2021-07-14 · Fire 2021-07-14

3 health deficiencies

Top issue: Resident Rights (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2019-03-20 · Fire 2019-03-20

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

12 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2018-03-02 · Fire 2018-03-02

19 health 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 citations

E · Potential for more than minimal harm 2019-03-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

K321 · Smoke Deficiencies

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

D · Potential for more than minimal harm 2019-03-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

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 2019-04-27

D · Potential for more than minimal harm 2019-03-20

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2019-04-27

D · 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 2019-04-27

D · Potential for more than minimal harm 2019-03-20

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-04-27

D · Potential for more than minimal harm 2018-03-02

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2018-02-28

D · Potential for more than minimal harm 2018-03-02

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2018-02-28

D · Potential for more than minimal harm 2018-03-02

K321 · Smoke Deficiencies

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

D · Potential for more than minimal harm 2018-03-02

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2018-02-28

D · Potential for more than minimal harm 2018-03-02

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2018-02-28

D · Potential for more than minimal harm 2018-03-02

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2018-02-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-03-12

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 2024-04-05

D · Potential for more than minimal harm 2024-03-12

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-04-05

D · Potential for more than minimal harm 2024-03-12

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 2024-04-05

D · Potential for more than minimal harm 2024-03-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-05

D · Potential for more than minimal harm 2024-03-12

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-05

D · Potential for more than minimal harm 2024-03-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-05

D · Potential for more than minimal harm 2023-09-13

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 2023-09-19

D · Potential for more than minimal harm 2023-09-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-19

D · Potential for more than minimal harm 2023-03-14

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 2023-05-12

D · Potential for more than minimal harm 2021-07-14

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 2021-09-02

D · Potential for more than minimal harm 2021-07-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2021-09-02

D · Potential for more than minimal harm 2021-07-14

F909 · Environmental Deficiencies

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

D · Potential for more than minimal harm 2019-03-20

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2019-04-27

D · Potential for more than minimal harm 2019-03-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-04-27

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 2019-04-27

D · Potential for more than minimal harm 2019-03-20

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 2019-04-27

J · Immediate jeopardy 2018-03-02

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 2018-03-20

J · Immediate jeopardy 2018-03-02

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 2018-03-20

J · Immediate jeopardy 2018-03-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-03-20

J · Immediate jeopardy 2018-03-02

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2018-03-20

J · Immediate jeopardy 2018-03-02

F842 · Resident Assessment and Care Planning Deficiencies

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

F · Potential for more than minimal harm 2018-03-02

F727 · Nursing and Physician Services Deficiencies

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

F · Potential for more than minimal harm 2018-03-02

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 2018-03-20

D · Potential for more than minimal harm 2018-03-02

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2018-03-20

D · Potential for more than minimal harm 2018-03-02

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 2018-03-20

D · Potential for more than minimal harm 2018-03-02

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2018-03-20

D · Potential for more than minimal harm 2018-03-02

F642 · Resident Assessment and Care Planning Deficiencies

Health

Ensure a qualified health professional conducts resident assessments.

Corrected 2018-03-20

D · Potential for more than minimal harm 2018-03-02

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 2018-03-20

D · Potential for more than minimal harm 2018-03-02

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2018-03-20

D · Potential for more than minimal harm 2018-03-02

F693 · Quality of Life and Care Deficiencies

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

D · Potential for more than minimal harm 2018-03-02

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2018-03-20

D · Potential for more than minimal harm 2018-03-02

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 2018-03-20

Penalties and ownership

What sits behind the stars

Ownership

Whites Creek Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2019-06-01
Ecm Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 6 facilities 2019-06-01
Eisen, Menashe

5% Or Greater Indirect Ownership Interest · Individual

0% 5 facilities 2019-06-01
Labin, Shiya

5% Or Greater Indirect Ownership Interest · Individual

0% 14 facilities 2019-06-01
Leech, Tracie

W-2 Managing Employee · Individual

0% 1 facilities 2019-06-01
Mcgovern, Benjamin

W-2 Managing Employee · Individual

0% 2 facilities 2019-06-01
Neuman, Benjamin

5% Or Greater Indirect Ownership Interest · Individual

0% 14 facilities 2019-06-01
Niederman, Anshel

5% Or Greater Indirect Ownership Interest · Individual

0% 18 facilities 2019-06-01
Niederman, Anshel

Corporate Officer · Individual

0% 18 facilities 2019-06-01
Philipson Family Limited Liability Company, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 26 facilities 2019-06-01
Philipson, Bent

5% Or Greater Indirect Ownership Interest · Individual

0% 13 facilities 2019-06-01
Vnb New York LLC

5% Or Greater Security Interest · Organization

0% 11 facilities 2019-06-01

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