Cycle 1
Health 2025-04-24 · Fire 2025-04-24
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Gallatin, TN
Gallatin Center For Rehabilitation And Healing
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
438 North Water Ave, Gallatin, TN
(615) 452-2322
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
207
Certified beds
Average residents
197
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1986-02-27
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
0.45
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,572
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.86
Baseline 16.45% · Performance 21.04% · Measure score 0.86 · Achievement 0.86 · Improvement 0
Healthcare-associated infections
0
Baseline 5.86% · Performance 8.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.58
Baseline 68.93% · Performance 64.19% · Measure score 0.58 · Achievement 0 · Improvement 0.58
Adjusted total nurse staffing
0
Baseline 2.82 hours · Performance 2.92 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.03% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 147 · Observed rate 17.01% · Lower 95% interval 9.81% |
| Discharge to community | 45.11% |
50.57%
5.5 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 35.56% · Lower 95% interval 33.84% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.17% |
95.27%
3.9 pts better
|
Numerator 119 · Denominator 120 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 120 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 39 · Denominator 69 |
| Discharge mobility score | 42.03% |
50.94%
8.9 pts worse
|
Numerator 29 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 0.83% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 120 · Adjusted rate 0.69% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 11.34% · Lower 95% interval 5.73% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 5 · Denominator 240 |
| Staff flu vaccination coverage | 11.49% |
42%
30.5 pts worse
|
Numerator 40 · Denominator 348 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 36 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 66 · Denominator 66 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 15 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · 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 | 99.4% |
89.9%
9.5 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 99.4% · Q3 99.4% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
94.5%
1.2 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.3% · Q3 6.0% · Q4 4.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
11.8%
5.7 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.5% · Q3 9.6% · Q4 5.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.2%
1.6 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.4% · Q3 5.3% · Q4 2.5% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
32.2%
3.9 pts better
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 28.0% · Q3 29.2% · Q4 26.2% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
18.1%
5.7 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.9% · Q3 12.4% · Q4 11.5% · 4Q avg 12.4% · 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 | 12.0% |
19.9%
7.9 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 8.8% · Q3 15.4% · Q4 7.2% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
15.3%
3.4 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 11.7% · Q3 12.9% · Q4 6.3% · 4Q avg 11.9% · 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 | 0.6% |
1.9%
1.3 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
20.2%
11.5 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.9% · Q3 5.9% · Q4 9.4% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.4%
1.3 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.1% · Q3 4.9% · Q4 2.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
79.6%
15 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 94.7% · Q3 95.6% · Q4 94.9% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
11.2%
1.9 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.5% · Expected 11.4% · 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 | 84.3% |
79.8%
4.5 pts better
|
79.7%
4.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
22.2%
0.1 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 23.2% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-28 · Fire 2023-04-28
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-03-26 · Fire 2019-03-26
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-24
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-19
F · Potential for more than minimal harm
2023-04-28
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-04-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-24
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
D · Potential for more than minimal harm
2023-04-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
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 2023-06-02
D · Potential for more than minimal harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-02
D · Potential for more than minimal harm
2019-03-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-05-01
D · Potential for more than minimal harm
2019-03-26
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 2019-05-01
D · Potential for more than minimal harm
2019-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-01
Penalties and ownership
What sits behind the stars
Ownership
Gallatin Tn Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Eme, Ijagha
Operational/Managerial Control · Individual
Friedman, Mark
5% Or Greater Indirect Ownership Interest · Individual
Friedman, Mark
Corporate Officer · Individual
Light, Beth
Operational/Managerial Control · Individual
Md Friedman Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Neal Einhorn Family 2017 Trust
5% Or Greater Indirect Ownership Interest · Organization
Pintilie, Adrienne
Operational/Managerial Control · Individual
Schwartz, Eliezer
5% Or Greater Indirect Ownership Interest · Individual
Zucker, Yossie
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
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The Waters Of Gallatin, LLC
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#2
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Gallatin, TN
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Signature Health Of Portland Rehab & Wellness Cent
Portland, TN
1-star overall rating with 1-star inspections with abuse icon flag with $107,228 in total fines with 9 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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