Cleveland, GA

Gateway Health And Rehab

4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

3201 Westmoreland Road, Cleveland, GA

(706) 865-5686

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

57

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Reliable Health Care Management

Operator or chain grouping

Approved since

1993-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 3 overall / 4 health / 1 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

0.19

Registered nurse staffing · state 0.49 · national 0.68

LPN hours / resident day

0.91

Licensed practical nurse staffing · state 0.93 · national 0.87

Aide hours / resident day

1.93

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.03

All reported nurse hours · state 3.57 · national 3.89

Licensed hours

1.10

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.71

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.22

Weekend registered nurse coverage · state 0.33 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.19

CMS adjusted RN staffing hours

Adjusted total hours

3.05

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

38%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,040

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.95

Composite VBP score used to determine payment impact.

Payment multiplier

0.9862

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

3.84

Performance 6.69% · Measure score 3.84 · Achievement 3.84 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

3.88

Baseline 50.00% · Performance 47.83% · Measure score 3.88 · Achievement 3.88 · Improvement 0.36

Adjusted total nurse staffing

1.57

Baseline 3.58 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.95%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 6.25% · Lower 95% interval 6.46%
Discharge to community	51.32%	50.57% 0.8 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 46.15% · Lower 95% interval 32.86%
Medicare spending per beneficiary	1.31	1.02 0.3 pts worse
Drug regimen review with follow-up	95.24%	95.27% About the same	Numerator 40 · Denominator 42
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 42
Discharge self-care score	25.81%	53.69% 27.9 pts worse	Numerator 8 · Denominator 31
Discharge mobility score	29.03%	50.94% 21.9 pts worse	Numerator 9 · Denominator 31
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 42 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.69%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.6%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 71
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	32.26%	56.45% 24.2 pts worse	Numerator 10 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	10%	25.2% 15.2 pts worse	Numerator 2 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.3	2.2 1.1 pts worse	1.9 1.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.4 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.1	2.0 0.1 pts worse	1.8 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	91.2% 7.8 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.0% 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	7.3%	3.2% 4.1 pts worse	3.3% 4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.9% · Q3 6.2% · Q4 6.0% · 4Q avg 7.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.0%	9.6% 4.6 pts better	11.4% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.3% · Q3 8.5% · Q4 2.1% · 4Q avg 5.0%
Percentage of long-stay residents who lose too much weight	3.6%	5.9% 2.3 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 5.1% · Q4 6.7% · 4Q avg 3.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	32.6%	20.7% 11.9 pts worse	19.6% 13 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 32.6% · Q3 33.3% · Q4 31.2% · 4Q avg 32.6%
Percentage of long-stay residents who received an antipsychotic medication	12.6%	21.4% 8.8 pts better	16.7% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 21.6% · Q3 8.3% · Q4 7.5% · 4Q avg 12.6% · 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	28.6%	17.9% 10.7 pts worse	16.3% 12.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 23.4% · Q3 32.0% · Q4 12.2% · 4Q avg 28.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	35.5%	16.2% 19.3 pts worse	14.9% 20.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 27.5% · Q3 45.2% · Q4 26.2% · 4Q avg 35.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.4%	1.1% 1.3 pts worse	1.0% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 7.5% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.2%	2.5% 3.7 pts worse	1.7% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.0% · Q3 4.8% · Q4 10.6% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.5%	16.1% 4.4 pts worse	19.8% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 27.5% · Q3 21.3% · Q4 20.6% · 4Q avg 20.5%
Percentage of long-stay residents with pressure ulcers	3.8%	6.2% 2.4 pts better	5.1% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 9.1% · Q3 2.1% · Q4 2.2% · 4Q avg 3.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.8%	80.4% 15.4 pts better	81.7% 14.1 pts better	Short Stay · 2024Q4-2025Q3 · Q3 96.2% · Q4 96.3% · 4Q avg 95.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.3%	12.2% 5.9 pts better	12.0% 5.7 pts better	Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.8% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.6%	2.2% 0.4 pts worse	1.6% 1 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.3%	24.2% 7.9 pts better	23.9% 7.6 pts better	Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.4% · Expected 22.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-23 · Fire 2025-03-23

1 health deficiencies

Top issue: Resident Rights (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-02-08 · Fire 2023-02-08

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2021-07-23 · Fire 2021-07-23

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-03-23

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-06

D · Potential for more than minimal harm 2025-03-23

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-05-06

D · Potential for more than minimal harm 2023-02-08

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-03-25

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-23

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 2025-05-06

D · Potential for more than minimal harm 2023-02-08

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 2023-03-25

D · Potential for more than minimal harm 2021-07-23

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2021-09-06

D · Potential for more than minimal harm 2021-07-23

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 2021-09-06

C · Minimal harm 2021-07-23

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2021-09-06

Penalties and ownership

What sits behind the stars

Ownership

Employee Stock Ownership Plan Of Select Health Care Inc Trust

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 2009-07-01

Bilbo, Richard