Goodlettsville, TN

Alta Heights Post Acute

2-star overall rating with 2-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

813 S Dickerson Rd, Goodlettsville, TN

(615) 859-6600

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

90

Certified beds

Average residents

67

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

2002-10-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 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

0.54

Registered nurse staffing · state 0.61 · national 0.68

LPN hours / resident day

1.20

Licensed practical nurse staffing · state 1.09 · national 0.87

Aide hours / resident day

1.99

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.73

All reported nurse hours · state 3.85 · national 3.89

Licensed hours

1.75

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

3.68

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

69%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

67%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,581

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

Performance score

11.59

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.75% · Performance 21.34% · Measure score 0 · Achievement 0 · Improvement 0

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

2.57

Baseline 65.82% · Performance 53.25% · Measure score 2.57 · Achievement 2.55 · Improvement 2.57

Adjusted total nurse staffing

0.91

Baseline 2.79 hours · Performance 3.21 hours · Measure score 0.91 · Achievement 0 · Improvement 0.91

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.07%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 48 · Observed rate 14.58% · Lower 95% interval 6.75%
Discharge to community	41.03%	50.57% 9.5 pts worse	No Different than the National Rate · Eligible stays 43 · Observed rate 30.23% · Lower 95% interval 27.89%
Medicare spending per beneficiary	0.99	1.02 About the same
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 77
Staff flu vaccination coverage	63.75%	42% 21.8 pts better	Numerator 51 · Denominator 80
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	47.6%	89.9% 42.3 pts worse	93.4% 45.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 14.8% · Q3 66.1% · Q4 89.7% · 4Q avg 47.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	64.4%	94.5% 30.1 pts worse	95.5% 31.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 64.4%
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 1.7% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	19.3%	11.8% 7.5 pts worse	11.4% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 32.0% · Q4 49.1% · 4Q avg 19.3%
Percentage of long-stay residents who lose too much weight	1.4%	6.2% 4.8 pts better	5.4% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 1.9% · 4Q avg 1.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.6%	32.2% 2.6 pts better	19.6% 10 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 20.7% · Q3 37.3% · Q4 27.3% · 4Q avg 29.6%
Percentage of long-stay residents who received an antipsychotic medication	37.3%	18.1% 19.2 pts worse	16.7% 20.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 38.5% · Q3 34.2% · Q4 34.2% · 4Q avg 37.3% · 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	15.6%	19.9% 4.3 pts better	16.3% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.7%	15.3% 1.4 pts worse	14.9% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 21.2% · Q3 2.1% · Q4 20.0% · 4Q avg 16.7% · 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	3.7%	1.9% 1.8 pts worse	1.7% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.4% · Q3 1.8% · Q4 3.5% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.1%	20.2% 1.1 pts better	19.8% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 16.7% · Q3 16.8% · Q4 21.9% · 4Q avg 19.1%
Percentage of long-stay residents with pressure ulcers	7.8%	5.4% 2.4 pts worse	5.1% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 8.3% · Q3 7.1% · Q4 4.1% · 4Q avg 7.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	35.4%	79.6% 44.2 pts worse	81.7% 46.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 7.5% · Q3 55.0% · Q4 69.1% · 4Q avg 35.4%
Percentage of short-stay residents who had an outpatient emergency department visit	18.3%	11.2% 7.1 pts worse	12.0% 6.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 21.9% · Expected 13.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.6% 0.7 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	2.1%	79.8% 77.7 pts worse	79.7% 77.6 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 2.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	22.7%	22.2% 0.5 pts worse	23.9% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 31.2% · Expected 32.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-27 · Fire 2025-02-27

12 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2019-11-19 · Fire 2019-11-19

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2018-10-17 · Fire 2018-10-17

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-27

K232 · Egress Deficiencies

Fire Safety

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

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K364 · Smoke Deficiencies

Fire Safety

Install properly constructed windows in hallway walls or doors.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K900 · Miscellaneous Deficiencies

Fire Safety

Meet Health Care Facilities Code mechanical requirements.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-04-11

F · Potential for more than minimal harm 2019-11-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-01-03

D · Potential for more than minimal harm 2019-11-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-01-03

D · Potential for more than minimal harm 2019-11-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-01-03

C · Minimal harm 2019-11-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2020-01-03

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-27

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 2025-04-11

E · Potential for more than minimal harm 2025-02-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-11

E · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

D · Potential for more than minimal harm 2025-02-27

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-04-11

D · Potential for more than minimal harm 2025-02-27

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 2025-04-11

J · Immediate jeopardy 2019-11-19

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2020-01-03

J · Immediate jeopardy 2019-11-19

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 2020-01-03

D · Potential for more than minimal harm 2019-11-19

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 2020-01-03

D · Potential for more than minimal harm 2019-11-19

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 2020-01-03

D · Potential for more than minimal harm 2019-11-19

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 2020-01-03

D · Potential for more than minimal harm 2019-11-19

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 2020-01-03

Penalties and ownership