Cycle 1
Health 2022-05-12 · Fire 2022-05-12
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bartlett, TN
Ave Maria Home
2-star overall rating with 2-star inspections with $27,921 in total fines with 5 recent health deficiencies
2805 Charles Bryan Rd, Bartlett, TN
(901) 386-3211
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.57
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.62
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
3.91
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
6.10
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
5.41
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
6.56
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,446
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.74
Composite VBP score used to determine payment impact.
Payment multiplier
1.0037
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.29
Baseline 19.20% · Performance 20.37% · Measure score 2.29 · Achievement 2.29 · Improvement 0
Healthcare-associated infections
6.17
Baseline 8.94% · Performance 6.31% · Measure score 6.17 · Achievement 5.11 · Improvement 6.17
Total nurse turnover
1.43
Baseline 60.81% · Performance 57.82% · Measure score 1.43 · Achievement 1.43 · Improvement 0.33
Adjusted total nurse staffing
10
Baseline 6.83 hours · Performance 6.07 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 247 · Observed rate 6.88% · Lower 95% interval 6.77% |
| Discharge to community | 56.29% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 52.94% · Lower 95% interval 49.29% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 162 · Denominator 165 |
| Falls with major injury | 1.21% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 165 |
| Discharge self-care score | 61.26% |
53.69%
7.6 pts better
|
Numerator 68 · Denominator 111 |
| Discharge mobility score | 63.96% |
50.94%
13 pts better
|
Numerator 71 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 165 · Adjusted rate 2.91% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 4.8% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 11.81% |
8.2%
3.6 pts better
|
Numerator 15 · Denominator 127 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 65.77% |
56.45%
9.3 pts better
|
Numerator 73 · Denominator 111 |
| Transfer of health information to provider | 40% |
95.95%
56 pts worse
|
Numerator 20 · Denominator 50 |
| Transfer of health information to patient | 94.74% |
96.28%
1.5 pts worse
|
Numerator 90 · Denominator 95 |
| Resident COVID-19 vaccinations up to date | 7.45% |
25.2%
17.8 pts worse
|
Numerator 7 · Denominator 94 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
89.9%
3.6 pts better
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.4% · Q3 82.5% · Q4 95.1% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.5%
2.3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.9% · Q3 3.2% · Q4 1.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
11.8%
11.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
6.2%
5.2 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
32.2%
8.5 pts better
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 23.1% · Q3 23.5% · Q4 27.5% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
18.1%
4.1 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 22.5% · Q3 20.0% · Q4 22.7% · 4Q avg 22.2% · 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 | 42.2% |
19.9%
22.3 pts worse
|
16.3%
25.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.0% |
15.3%
17.7 pts worse
|
14.9%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 35.4% · Q3 25.5% · Q4 32.6% · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
0.9%
1.6 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.2% · Q3 3.5% · Q4 2.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.9%
1.4 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.3% · Q3 3.2% · Q4 3.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
20.2%
1.4 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 24.7% · Q3 24.9% · Q4 13.8% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.4%
2.8 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 9.1% · Q3 8.3% · Q4 2.6% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
79.6%
4.4 pts better
|
81.7%
2.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 80.4% · Q3 84.7% · Q4 88.0% · 4Q avg 84.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
11.2%
4.3 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.6%
0.8 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 0.9% · Q4 2.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.2% |
79.8%
9.6 pts worse
|
79.7%
9.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.2%
5.7 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 24.6% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-21 · Fire 2020-02-21
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-21
K524 · Services Deficiencies
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2020-03-06
D · Potential for more than minimal harm
2019-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-04-15
Inspection history
Recent health citations
J · Immediate jeopardy
2024-03-28
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 2024-07-02
E · Potential for more than minimal harm
2022-05-12
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 2022-06-20
D · Potential for more than minimal harm
2022-05-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-06-10
D · Potential for more than minimal harm
2022-05-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-05-23
D · Potential for more than minimal harm
2022-05-12
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 2022-05-23
D · Potential for more than minimal harm
2022-05-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-03
D · Potential for more than minimal harm
2020-02-21
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 2020-03-06
D · Potential for more than minimal harm
2020-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-06
F · Potential for more than minimal harm
2019-03-07
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 2019-04-15
E · Potential for more than minimal harm
2019-03-07
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 2019-04-15
E · Potential for more than minimal harm
2019-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-03-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-03-07
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 2019-04-15
E · Potential for more than minimal harm
2019-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-07
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 2019-04-15
D · Potential for more than minimal harm
2019-03-07
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 2019-04-15
D · Potential for more than minimal harm
2019-03-07
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-07
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 2019-04-15
Penalties and ownership
What sits behind the stars
$10,039
2024-03-28
Fine
Fine · fine $10,039
Fine
$17,882
2024-03-28
Fine
Fine · fine $17,882
Fine
$0
2024-03-28
Payment Denial
Payment Denial · denial start 2024-03-30 · 94 days
94 day denial
Ownership
Gattuso, Frank
Corporate Director · Individual
Siegel, Marlene
W-2 Managing Employee · Individual
Nearby options
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#3
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