Cookeville, TN

Ahc Bethesda

2-star overall rating with 2-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

444 One Eleven Place, Cookeville, TN

(931) 525-6655

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

American Health Communities

Operator or chain grouping

Approved since

2001-07-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

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

0.52

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.30

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

2.04

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.85

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.82

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.38

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.13

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.34

CMS adjusted total nurse staffing hours

Case-mix index

1.58

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,738

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.84

Composite VBP score used to determine payment impact.

Payment multiplier

0.9867

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.22

Baseline 22.31% · Performance 19.81% · Measure score 4.22 · Achievement 3.49 · Improvement 4.22

Healthcare-associated infections

2.73

Baseline 8.19% · Performance 7.15% · Measure score 2.73 · Achievement 2.28 · Improvement 2.73

Total nurse turnover

4.32

Baseline 46.30% · Performance 46.03% · Measure score 4.32 · Achievement 4.32 · Improvement 0

Adjusted total nurse staffing

1.46

Baseline 2.31 hours · Performance 2.99 hours · Measure score 1.46 · Achievement 0 · Improvement 1.46

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.95%	10.72% 0.2 pts worse	No Different than the National Rate · Eligible stays 120 · Observed rate 14.17% · Lower 95% interval 8.22%
Discharge to community	38.69%	50.57% 11.9 pts worse	Worse than the National Rate · Eligible stays 108 · Observed rate 27.78% · Lower 95% interval 28.92%
Medicare spending per beneficiary	1.23	1.02 0.2 pts worse
Drug regimen review with follow-up	98.67%	95.27% 3.4 pts better	Numerator 74 · Denominator 75
Falls with major injury	1.33%	0.77% 0.6 pts worse	Numerator 1 · Denominator 75
Discharge self-care score	18.18%	53.69% 35.5 pts worse	Numerator 6 · Denominator 33
Discharge mobility score	9.09%	50.94% 41.8 pts worse	Numerator 3 · Denominator 33
Pressure ulcers or injuries, new or worsened	2.67%	2.29% 0.4 pts worse	Numerator 2 · Denominator 75 · Adjusted rate 2.49%
Healthcare-associated infections requiring hospitalization	7.15%	7.12% About the same	No Different than the National Rate · Eligible stays 70 · Observed rate 7.14% · Lower 95% interval 4.16%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 112
Staff flu vaccination coverage	24.82%	42% 17.2 pts worse	Numerator 34 · Denominator 137
Discharge function score	18.18%	56.45% 38.3 pts worse	Numerator 6 · Denominator 33
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 20 · Denominator 20
Transfer of health information to patient	96.43%	96.28% 0.2 pts better	Numerator 27 · Denominator 28
Resident COVID-19 vaccinations up to date	12.77%	25.2% 12.4 pts worse	Numerator 6 · Denominator 47

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.6 About the same	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.3 · Expected 2.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.9	1.6 0.3 pts worse	1.8 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.4%	89.9% 8.5 pts better	93.4% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 98.1% · Q4 97.0% · 4Q avg 98.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	94.5% 4.1 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	3.7%	3.6% 0.1 pts worse	3.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.7% · Q3 1.9% · Q4 6.1% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	46.4%	11.8% 34.6 pts worse	11.4% 35 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 34.0% · Q3 82.0% · Q4 61.8% · 4Q avg 46.4%
Percentage of long-stay residents who lose too much weight	5.9%	6.2% 0.3 pts better	5.4% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 7.5% · Q3 0.0% · Q4 8.6% · 4Q avg 5.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	52.8%	32.2% 20.6 pts worse	19.6% 33.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 52.3% · Q2 50.9% · Q3 53.1% · Q4 54.8% · 4Q avg 52.8%
Percentage of long-stay residents who received an antipsychotic medication	19.1%	18.1% 1 pts worse	16.7% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 27.5% · Q3 25.0% · Q4 10.0% · 4Q avg 19.1% · 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	12.1%	19.9% 7.8 pts better	16.3% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q4 3.8% · 4Q avg 12.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.7%	15.3% 2.6 pts better	14.9% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 9.6% · Q3 8.5% · Q4 10.0% · 4Q avg 12.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	0.9% 0.5 pts worse	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 2.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.7%	1.9% 2.8 pts worse	1.7% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.6% · Q3 6.0% · Q4 4.8% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	16.9%	20.2% 3.3 pts better	19.8% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.9% · Q3 15.2% · Q4 10.9% · 4Q avg 16.9%
Percentage of long-stay residents with pressure ulcers	8.0%	5.4% 2.6 pts worse	5.1% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.7% · Q3 6.9% · Q4 5.4% · 4Q avg 8.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.8%	79.6% 14.2 pts better	81.7% 12.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 93.6% · Q3 91.5% · Q4 96.8% · 4Q avg 93.8%
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	11.2% 0.4 pts better	12.0% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 11.4% · Expected 11.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.6% 0.6 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.8%	79.8% 14 pts better	79.7% 14.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.6%	22.2% 3.4 pts worse	23.9% 1.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 29.1% · Expected 27.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-06 · Fire 2025-05-06

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2022-03-31 · Fire 2022-03-31

21 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2019-06-12 · Fire 2019-06-12

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-05-06

E30 · Emergency Preparedness Deficiencies

Fire Safety

List the names and contact information of those in the facility.

Corrected 2025-06-22

D · Potential for more than minimal harm 2025-05-06

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-22

D · Potential for more than minimal harm 2025-05-06

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-06-22

D · Potential for more than minimal harm 2025-05-06

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-06-22

D · Potential for more than minimal harm 2022-03-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-05-12

D · Potential for more than minimal harm 2019-06-12

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

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 2019-07-24

D · Potential for more than minimal harm 2019-06-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-07-24

D · Potential for more than minimal harm 2019-06-12

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2019-07-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-01-21

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2026-02-20

F · Potential for more than minimal harm 2025-05-06

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-06-22

E · Potential for more than minimal harm 2025-05-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-22

D · Potential for more than minimal harm 2025-05-06

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 2025-06-22

D · Potential for more than minimal harm 2025-05-06

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 2025-06-22

D · Potential for more than minimal harm 2025-05-06

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-06-22

E · Potential for more than minimal harm 2024-05-21

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 2024-07-17

D · Potential for more than minimal harm 2024-05-21

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 2024-07-17

D · Potential for more than minimal harm 2024-05-21

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-07-17

D · Potential for more than minimal harm 2023-09-27

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 2023-10-31

D · Potential for more than minimal harm 2023-09-27

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 2023-10-31

D · Potential for more than minimal harm 2023-09-27

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 2023-10-31

D · Potential for more than minimal harm 2023-09-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-10-31

F · Potential for more than minimal harm 2022-03-31

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-05-12

F · Potential for more than minimal harm 2022-03-31

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 2022-05-12

F · Potential for more than minimal harm 2022-03-31

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 2022-05-12

F · Potential for more than minimal harm 2022-03-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-12

E · Potential for more than minimal harm 2022-03-31

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 2022-05-12

E · Potential for more than minimal harm 2022-03-31

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 2022-05-12

E · Potential for more than minimal harm 2022-03-31

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-05-12

E · Potential for more than minimal harm 2022-03-31

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

D · Potential for more than minimal harm 2022-03-31

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

D · Potential for more than minimal harm 2022-03-31

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-05-12

D · Potential for more than minimal harm 2022-03-31

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

D · Potential for more than minimal harm 2022-03-31

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2022-05-12

D · Potential for more than minimal harm 2022-03-31

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 2022-05-12

G · Actual harm 2019-06-12

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 2019-07-12

F · Potential for more than minimal harm 2019-06-12

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 2019-07-12

E · Potential for more than minimal harm 2019-06-12