Cycle 1
Health 2023-06-01 · Fire 2023-06-01
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Maynardville, TN
Willow Ridge Center
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
215 Richardson Way, Maynardville, TN
(865) 992-5816
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1992-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 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
0.78
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.58
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
2.65
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,814
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.36
Baseline 36.21% · Performance 29.51% · Measure score 8.36 · Achievement 8.36 · Improvement 5.40
Adjusted total nurse staffing
0.15
Baseline 2.68 hours · Performance 2.89 hours · Measure score 0.15 · Achievement 0 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 6.93% |
| Discharge to community | 40.14% |
50.57%
10.4 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 20% · Lower 95% interval 24.27% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 24% |
53.69%
29.7 pts worse
|
Numerator 6 · Denominator 25 |
| Discharge mobility score | 32% |
50.94%
18.9 pts worse
|
Numerator 8 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 75 |
| Staff flu vaccination coverage | 75.96% |
42%
34 pts better
|
Numerator 79 · Denominator 104 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 9 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 22 |
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 1.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
89.9%
About the same
|
93.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.5% · Q2 86.7% · Q3 94.7% · Q4 98.2% · 4Q avg 89.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
94.5%
9.7 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.6%
3.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.8% |
11.8%
30 pts worse
|
11.4%
30.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 59.6% · Q3 38.9% · Q4 18.9% · 4Q avg 41.8% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
6.2%
4.3 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 4.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 53.1% |
32.2%
20.9 pts worse
|
19.6%
33.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.6% · Q2 56.6% · Q3 52.8% · Q4 43.8% · 4Q avg 53.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
18.1%
3.9 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 13.2% · Q3 14.6% · Q4 12.5% · 4Q avg 14.2% · 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 | 28.2% |
19.9%
8.3 pts worse
|
16.3%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
15.3%
0.3 pts worse
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 21.4% · Q3 11.1% · Q4 16.7% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.9%
0.7 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 1.8% · Q4 5.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
20.2%
1.8 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 18.3% · Q3 7.1% · Q4 20.1% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.4%
0.6 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.7% · Q3 6.8% · Q4 1.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.5% |
79.6%
4.1 pts worse
|
81.7%
6.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.3% · Q2 70.2% · Q3 80.0% · Q4 84.3% · 4Q avg 75.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.2%
11.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.7% · 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 | 75.5% |
79.8%
4.3 pts worse
|
79.7%
4.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
22.2%
4.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.4% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-07 · Fire 2021-12-07
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-21 · Fire 2019-05-21
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-27
F · Potential for more than minimal harm
2023-06-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-05
F · Potential for more than minimal harm
2023-06-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-06-01
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 2023-06-20
D · Potential for more than minimal harm
2023-06-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-19
D · Potential for more than minimal harm
2023-06-01
K905 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that gas containers are correctly designed and tested, and in locations that are labeled.
Corrected 2023-06-02
F · Potential for more than minimal harm
2021-12-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-29
F · Potential for more than minimal harm
2019-05-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-06-26
F · Potential for more than minimal harm
2019-05-21
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-06-01
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 2023-06-30
E · Potential for more than minimal harm
2023-06-01
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
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 2023-06-21
D · Potential for more than minimal harm
2023-06-01
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 2023-06-21
D · Potential for more than minimal harm
2023-06-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-21
D · Potential for more than minimal harm
2021-12-07
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 2021-12-07
D · Potential for more than minimal harm
2021-12-07
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 2022-01-01
D · Potential for more than minimal harm
2021-12-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-12-07
G · Actual harm
2019-05-21
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 2019-06-26
G · Actual harm
2019-05-21
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 2019-06-26
F · Potential for more than minimal harm
2019-05-21
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 2019-06-26
E · Potential for more than minimal harm
2019-05-21
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-21
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 2019-06-26
D · Potential for more than minimal harm
2019-05-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-06-26
Penalties and ownership
What sits behind the stars
Ownership
Regency Health Services, LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Cupp, Steven
Operational/Managerial Control · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Sun Healthcare Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Sunbridge Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Whitman, Arnold
Corporate Director · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Ridgeview Terrace Of Life Care
Rutledge, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Andersonville Tn Opco LLC
Andersonville, TN
2-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Beverly Park Place Health And Rehab
Knoxville, TN
2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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