Cycle 1
Health 2022-06-23 · Fire 2022-06-23
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Etowah, TN
Etowah Health And Rehabilitation
2-star overall rating with 2-star inspections with $21,692 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
409 Grady Road, Etowah, TN
(423) 263-1138
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
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-12-08
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
0.68
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.31
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
11,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
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
1.94
Baseline 49.23% · Performance 55.74% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Adjusted total nurse staffing
1.14
Baseline 3.58 hours · Performance 3.40 hours · Measure score 1.14 · Achievement 1.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 6.51% |
| Discharge to community | 36.54% |
50.57%
14 pts worse
|
Worse than the National Rate · Eligible stays 26 · Observed rate 23.08% · Lower 95% interval 22.31% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · 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 15 · 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 84 |
| Staff flu vaccination coverage | 18.37% |
42%
23.6 pts worse
|
Numerator 9 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
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 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
89.9%
6.9 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 100.0% · Q3 100.0% · Q4 89.7% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.5%
1.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
11.8%
9.6 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.4% · Q4 5.3% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.2%
1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 17.1% · Q3 3.0% · Q4 6.5% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 50.0% |
32.2%
17.8 pts worse
|
19.6%
30.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.0% · Q2 48.6% · Q3 44.1% · Q4 51.5% · 4Q avg 50.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
18.1%
5.3 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 16.7% · Q3 24.0% · Q4 25.0% · 4Q avg 23.4% · 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 | 30.2% |
19.9%
10.3 pts worse
|
16.3%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
15.3%
8.5 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 22.6% · Q3 34.5% · Q4 25.9% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.9%
2.4 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 6.1% · Q3 2.3% · Q4 8.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.9% |
20.2%
17.7 pts worse
|
19.8%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 38.6% · Q3 20.3% · Q4 62.5% · 4Q avg 37.9% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.4%
1.5 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 10.2% · Q3 6.4% · Q4 2.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
79.6%
14.8 pts better
|
81.7%
12.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.6% · Q4 83.3% · 4Q avg 94.4% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
79.8%
6.4 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-26 · Fire 2019-06-26
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-06-28 · Fire 2018-06-28
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-19
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-09-04
F · Potential for more than minimal harm
2025-08-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-04
D · Potential for more than minimal harm
2025-08-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-09-04
D · Potential for more than minimal harm
2022-06-23
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-08-07
D · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-07
D · Potential for more than minimal harm
2022-06-23
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-08-07
D · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-07
F · Potential for more than minimal harm
2019-06-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-10
F · Potential for more than minimal harm
2019-06-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-08-10
F · Potential for more than minimal harm
2018-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2018-08-12
C · Minimal harm
2018-06-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-08-12
Inspection history
Recent health citations
G · Actual harm
2023-10-25
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 2023-12-01
G · Actual harm
2023-10-25
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 2023-12-01
J · Immediate jeopardy
2023-09-08
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 2023-09-02
F · Potential for more than minimal harm
2022-06-23
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 2022-08-26
E · Potential for more than minimal harm
2022-06-23
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-08-26
E · Potential for more than minimal harm
2022-06-23
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 2022-08-26
D · Potential for more than minimal harm
2022-06-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-23
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 2022-08-26
D · Potential for more than minimal harm
2022-06-23
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-23
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-26
D · Potential for more than minimal harm
2019-06-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-08-10
D · Potential for more than minimal harm
2019-06-26
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 2019-08-10
E · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
D · Potential for more than minimal harm
2018-06-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-08-12
D · Potential for more than minimal harm
2018-06-28
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 2018-08-12
Penalties and ownership
What sits behind the stars
$4,934
2023-10-25
Fine
Fine · fine $4,934
Fine
$7,443
2023-10-25
Fine
Fine · fine $7,443
Fine
$9,315
2023-09-08
Fine
Fine · fine $9,315
Fine
Ownership
Buchanan, Robert
5% Or Greater Direct Ownership Interest · Individual
John M Faust Living Trust
5% Or Greater Direct Ownership Interest · Organization
Baker, Suzanna
5% Or Greater Direct Ownership Interest · Individual
Wallstedt, Leslie
5% Or Greater Direct Ownership Interest · Individual
Hicks, Jonathon
W-2 Managing Employee · Individual
Holt, Jeffrey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Starr Regional Health & Rehabilitation
Etowah, TN
3-star overall rating with 3-star inspections with $8,697 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Nhc Healthcare, Athens
Athens, TN
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Life Care Center Of Athens
Athens, TN
5-star overall rating with 5-star inspections with 6 fire-safety deficiencies in the latest cycle
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