Cycle 1
Health 2022-08-30 · Fire 2022-08-30
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Decatur, TN
Decatur Wellness And Rehabilitation Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
332 River Road, Decatur, TN
(423) 334-3002
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
2017-11-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.37
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.39
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
1.46
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,921
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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
2.31
Baseline 77.50% · Performance 62.71% · Measure score 2.31 · Achievement 0 · Improvement 2.31
Adjusted total nurse staffing
2.10
Baseline 3.26 hours · Performance 3.67 hours · Measure score 2.10 · Achievement 2.10 · Improvement 1.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · 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 72 |
| Staff flu vaccination coverage | 23.53% |
42%
18.5 pts worse
|
Numerator 12 · Denominator 51 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.4% |
3.6%
2.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · 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 11.1% · Q2 24.2% · Q3 14.7% · Q4 6.9% · 4Q avg 14.4% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.2%
2.9 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 3.2% · Q4 3.4% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.5% |
32.2%
6.3 pts worse
|
19.6%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.2% · Q2 41.9% · Q3 32.3% · Q4 34.5% · 4Q avg 38.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
18.1%
7.7 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 10.4% · 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 | 12.4% |
19.9%
7.5 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
15.3%
3 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.7% · Q3 16.1% · Q4 13.8% · 4Q avg 12.3% · 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 | 0.7% |
1.9%
1.2 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
20.2%
1 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 26.9% · Q3 24.8% · Q4 18.6% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.4%
2.2 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.6% · Q3 5.2% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
79.6%
10.3 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 87.0% · Q3 92.7% · Q4 88.1% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
11.2%
5.9 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 18.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
79.8%
5.4 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.8% |
22.2%
14.6 pts worse
|
23.9%
12.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.8% · Observed 36.4% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-24 · Fire 2019-09-24
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-28 · Fire 2018-11-28
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-13
D · Potential for more than minimal harm
2022-08-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-13
F · Potential for more than minimal harm
2019-09-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-08
F · Potential for more than minimal harm
2019-09-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-11-08
D · Potential for more than minimal harm
2019-09-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-08
F · Potential for more than minimal harm
2018-11-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-14
F · Potential for more than minimal harm
2018-11-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-12-14
D · Potential for more than minimal harm
2018-11-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-12-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-01-17
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 2024-02-09
D · Potential for more than minimal harm
2024-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
D · Potential for more than minimal harm
2023-11-09
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 2023-11-28
D · Potential for more than minimal harm
2022-08-30
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 2022-10-13
D · Potential for more than minimal harm
2019-09-24
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 2019-10-14
D · Potential for more than minimal harm
2019-09-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-14
E · Potential for more than minimal harm
2018-11-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-12-14
D · Potential for more than minimal harm
2018-11-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-12-14
D · Potential for more than minimal harm
2018-11-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-14
Penalties and ownership
What sits behind the stars
Ownership
Decatur Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Ecm Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Eisen, Menashe
5% Or Greater Indirect Ownership Interest · Individual
Labin, Shiya
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Niederman, Anshel
5% Or Greater Indirect Ownership Interest · Individual
Niederman, Anshel
Corporate Officer · Individual
Philipson Family Limited Liability Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Philipson, Bent
5% Or Greater Indirect Ownership Interest · Individual
Sherlin, Linda
W-2 Managing Employee · Individual
Vnb New York LLC
5% Or Greater Security Interest · Organization
Wiggins, Megan
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Life Care Center Of Rhea County
Dayton, TN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Athens
Athens, TN
5-star overall rating with 5-star inspections with 6 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Athens
Athens, TN
4-star overall rating with 4-star inspections with 6 recent health deficiencies
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