Cycle 1
Health 2025-04-11 · Fire 2025-04-11
6 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Nashville, TN
Bethany Center For Rehabilitation And Healing LLC
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
421 Ocala Drive, Nashville, TN
(615) 834-4214
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
172
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1983-10-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.41
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.09
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.87
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
74%
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
8,061
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.76
Baseline 18.24% · Performance 19.23% · Measure score 4.76 · Achievement 4.76 · Improvement 0
Healthcare-associated infections
2.26
Baseline 5.29% · Performance 7.16% · Measure score 2.26 · Achievement 2.26 · Improvement 0
Total nurse turnover
4.15
Baseline 60.96% · Performance 46.70% · Measure score 4.15 · Achievement 4.15 · Improvement 3.45
Adjusted total nurse staffing
0
Baseline 3.09 hours · Performance 2.94 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 7.38% · Lower 95% interval 6.88% |
| Discharge to community | 48.64% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 137 · Observed rate 44.53% · Lower 95% interval 41.9% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 191 · Denominator 191 |
| Falls with major injury | 1.05% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 191 |
| Discharge self-care score | 55.71% |
53.69%
2 pts better
|
Numerator 78 · Denominator 140 |
| Discharge mobility score | 52.14% |
50.94%
1.2 pts better
|
Numerator 73 · Denominator 140 |
| Pressure ulcers or injuries, new or worsened | 2.62% |
2.29%
0.3 pts worse
|
Numerator 5 · Denominator 191 · Adjusted rate 2.45% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 93 · Observed rate 6.45% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 253 |
| Staff flu vaccination coverage | 17.93% |
42%
24.1 pts worse
|
Numerator 71 · Denominator 396 |
| Discharge function score | 61.43% |
56.45%
5 pts better
|
Numerator 86 · Denominator 140 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 74 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 45.19% |
25.2%
20 pts better
|
Numerator 47 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.6
1.2 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
89.9%
9 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 99.3% · Q4 97.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.6%
2 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.1% · Q3 5.2% · Q4 5.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.4% |
11.8%
2.6 pts worse
|
11.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 11.8% · Q3 12.3% · Q4 16.8% · 4Q avg 14.4% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.2%
1.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 4.4% · Q3 0.9% · Q4 3.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.8% |
32.2%
9.6 pts worse
|
19.6%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 43.2% · Q3 42.5% · Q4 38.0% · 4Q avg 41.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
18.1%
3.4 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.3% · Q3 16.0% · Q4 12.6% · 4Q avg 14.7% · 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 | 15.4% |
19.9%
4.5 pts better
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 21.0% · Q3 14.5% · Q4 16.7% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
15.3%
4.3 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 11.3% · Q3 10.2% · Q4 9.9% · 4Q avg 11.0% · 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 | 1.9% |
1.9%
About the same
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.1% · Q3 2.3% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
20.2%
3.6 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 22.2% · Q3 23.5% · Q4 27.2% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.4%
0.4 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.2% · Q3 8.1% · Q4 5.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
79.6%
18.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.2% · Q3 98.2% · Q4 99.6% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.2%
2.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.6%
1.1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
79.8%
17.5 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.2%
4.2 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-23 · Fire 2019-10-23
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-07-11 · Fire 2018-07-11
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-11
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-20
D · Potential for more than minimal harm
2018-07-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-08-17
D · Potential for more than minimal harm
2018-07-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-08-17
D · Potential for more than minimal harm
2018-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-08-17
D · Potential for more than minimal harm
2018-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-08-17
D · Potential for more than minimal harm
2018-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-08-17
D · Potential for more than minimal harm
2018-07-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-08-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-11
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 2025-05-20
D · Potential for more than minimal harm
2025-04-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
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 2025-05-20
D · Potential for more than minimal harm
2025-04-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
D · Potential for more than minimal harm
2023-08-18
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 2023-09-16
K · Immediate jeopardy
2019-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-11-12
G · Actual harm
2018-07-11
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 2018-08-03
D · Potential for more than minimal harm
2018-07-11
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 2018-08-03
D · Potential for more than minimal harm
2018-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-03
Penalties and ownership
What sits behind the stars
Ownership
Bethany Ventures Tn LLC
5% Or Greater Direct Ownership Interest · Organization
Einhorn, Neal
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Mark
5% Or Greater Indirect Ownership Interest · Individual
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Zucker, Yossie
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Mark
Operational/Managerial Control · Individual
Friedman, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Antioch, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $167,771 in total fines with 17 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Somerfield At The Heritage
Brentwood, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Woodcrest At Blakeford
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5-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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