Landscape of Nursing Home Facilities in Tennessee

Quality of Care Across the State

The CMS National Nursing Quality Care Collaborative developed a quality measure known as the Composite Score which is composed of 13 clinical measures.  The composite score measures quality on a systems perspective (national composite score benchmark is six (6) and under). As of April 2017, Tennessee is ranked 31st nationally for the percentage of nursing homes that have met the CMS goal of having a composite score of 6 or lower. Nearly 10% of the nation’s nursing homes have achieved a composite score of 6 or less. Figure A demonstrates the proposed funding awarded each year and state composite score goal in quarter three of each calendar year. Figure B shows Tennessee’s composite score for the state and average for facilities in each county from 2016. All the red dots indicate a nursing home with more than 18.26% of residents on an antipsychotic medication (national average = 15.1% in 2017Q4).


Figure A: Proposed Funding Awards and Composite Score Goals


Figure B: Tennessee Counties' Composite Score Average & Spotmap for High Antipsychotic Usage

Along with the Composite Scores to assess the quality of nursing home facilities, CMS established a Five-Star Quality Rating System to assist nursing home residents, potential residents and caretakers in asking necessary questions, making informed decisions related to care and in the selecting a nursing home facility. In Tennessee, there are currently 43 one-star facilities and 61 two-star facilities, some in counties where there may be no other long-term care options. Figure C depicts the location of the one star facilities and the number of nursing home facilities located in each county in Tennessee. Clusters of one-star and two-star facilities occur throughout the state.


Figure C: Tennessee One Star Nursing Homes
Map produced by Office of Patient Care Advocacy; Tennessee Department of Health

Long-Term Care Quality Improvement Initiatives

There are a number of national and state efforts aimed at quality improvement in long term care services including: the National Nursing Quality Care Collaborative led by CMS, Medicare Quality Improvement Organizations (QIO), CMS Five-Star Quality Rating System, and the TennCare Quality Improvement in Long Term Services and Supports’ (QuILTSS) initiative. The quality measures used to determine CMS Composite Scores, the national and state goals set forth by CMS, the sources to develop facilities’ star ratings, and TennCare’s QUILTSS initiative are outlined in Figure D.





  • Falls with major injury
  • UTI
  • Moderate to Severe Pain
  • Pressure Ulcer
  • Loss of Bowels of Bladder
  • Catheter left in Bladder
  • Physically Restrained
  • Need for help Increased
  • Lost too much Weight
  • Depressive Symptoms
  • Antipsychotic Medications
  • Flu Vaccine
  • Pneumococcal Vaccine
  • Satisfaction (resident, family, staff)
  • Culture Change/Quality of Life
  • Staffing/Staff Competency
  • Clinical Performance
    • Antipsychotic Medication
    • Urinary Tract Infection
  • Antipsychotic Reduction
  • Incontinence
  • Activities of Daily Living Decline
  • Health Acquired Infections
  • Health Inspections
    • Three years of onsite inspections (complaint and standard surveys)
  • Staffing rating
  • Quality Measures
    • Eleven physical and clinical measures for nursing home residents

Figure D: State and Federal Quality Measures and Standards