Cycle 1
Health 2021-07-15 · Fire 2021-07-15
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Gadsden, AL
Gadsden Health And Rehab Center
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1945 Davis Drive, Gadsden, AL
(256) 547-4938
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Preston Health Services
Operator or chain grouping
Approved since
1977-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 3 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
0.53
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,831
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.60% · Performance 27.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.11% · Performance 8.49% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.68
Baseline 3.77 hours · Performance 4.70 hours · Measure score 5.68 · Achievement 5.68 · Improvement 4.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.03% |
10.72%
4.3 pts worse
|
Worse than the National Rate · Eligible stays 219 · Observed rate 18.26% · Lower 95% interval 11.99% |
| Discharge to community | 47.87% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 43.38% · Lower 95% interval 42.91% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 185 · Denominator 186 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 186 |
| Discharge self-care score | 41.18% |
53.69%
12.5 pts worse
|
Numerator 42 · Denominator 102 |
| Discharge mobility score | 30.39% |
50.94%
20.5 pts worse
|
Numerator 31 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 1.08% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 186 · Adjusted rate 0.91% |
| Healthcare-associated infections requiring hospitalization | 8.49% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 9.42% · Lower 95% interval 5.82% |
| Staff COVID-19 vaccination coverage | 1.47% |
8.2%
6.7 pts worse
|
Numerator 3 · Denominator 204 |
| Staff flu vaccination coverage | 15.48% |
42%
26.5 pts worse
|
Numerator 65 · Denominator 420 |
| Discharge function score | 29.41% |
56.45%
27 pts worse
|
Numerator 30 · Denominator 102 |
| Transfer of health information to provider | 99.36% |
95.95%
3.4 pts better
|
Numerator 155 · Denominator 156 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.02% |
25.2%
18.2 pts worse
|
Numerator 8 · Denominator 114 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.0
1 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.3%
8.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 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 | 2.1% |
3.4%
1.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 1.0% · Q4 2.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 pts better
|
11.4%
11.4 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 who lose too much weight | 7.6% |
5.3%
2.3 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.0% · Q3 3.9% · Q4 6.9% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
24.9%
15.6 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 12.5% · Q4 10.2% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
22.8%
9.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.3% · Q3 10.3% · Q4 10.6% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 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 | 15.0% |
14.8%
0.2 pts worse
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 5.3% · Q3 4.6% · Q4 21.1% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
13.4%
3 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 9.8% · Q3 5.8% · Q4 9.2% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.3%
1.1 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.1% · Q3 3.2% · Q4 1.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
13.5%
7.2 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.4% · Q3 1.2% · Q4 4.6% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.7%
1.4 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 10.8% · Q3 6.1% · Q4 6.7% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
84.3%
14.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 98.1% · Q3 99.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
11.5%
1.9 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 11.4% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.1%
0.3 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.5% · Q3 1.6% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
80.3%
14.3 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
24.5%
3.1 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 35.9% · Expected 30.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-05 · Fire 2019-12-05
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-07-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-08-20
D · Potential for more than minimal harm
2021-07-15
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 2021-08-20
E · Potential for more than minimal harm
2019-12-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-13
F · Potential for more than minimal harm
2018-11-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-12-10
D · Potential for more than minimal harm
2018-11-01
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 2018-12-10
D · Potential for more than minimal harm
2018-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-10
D · Potential for more than minimal harm
2018-11-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-12-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-04-13
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 2023-05-18
D · Potential for more than minimal harm
2023-04-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-18
D · Potential for more than minimal harm
2021-07-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-07-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-07-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-08-13
D · Potential for more than minimal harm
2019-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-03
D · Potential for more than minimal harm
2018-11-01
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 2018-12-03
D · Potential for more than minimal harm
2018-11-01
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 2018-12-03
Penalties and ownership
What sits behind the stars
Ownership
Walker, James
5% Or Greater Direct Ownership Interest · Individual
Beckham, Nicholas
5% Or Greater Direct Ownership Interest · Individual
Mbs Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Preston Health Services Inc
Operational/Managerial Control · Organization
Reiland, Debora
Contracted Managing Employee · Individual
Weaver, Rachael
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Mcguffey Health & Rehabilitation Center
Gadsden, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Attalla Center For Rehabilitation And Nursing
Attalla, AL
2-star overall rating with 1-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Northside Health Care
Gadsden, AL
3-star overall rating with 3-star inspections with $340,800 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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