Cycle 1
Health 2025-11-19 · Fire 2025-11-19
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Huntsville, TN
Huntsville Post-Acute And Rehabilitation Center
1-star overall rating with 2-star inspections with $9,062 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
287 Baker Street, Huntsville, TN
(423) 663-3600
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-04-23
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
0.55
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.28
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
6,120
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9880
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.91
Performance 21.01% · Measure score 0.91 · Achievement 0.91 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.58
Performance 7.06% · Measure score 2.58 · Achievement 2.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.05
Baseline 37.31% · Performance 34.85% · Measure score 7.05 · Achievement 7.05 · Improvement 1.48
Adjusted total nurse staffing
3.03
Baseline 2.84 hours · Performance 3.88 hours · Measure score 3.03 · Achievement 2.83 · Improvement 3.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 15.69% · Lower 95% interval 7.07% |
| 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 | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 45.83% |
53.69%
7.9 pts worse
|
Numerator 11 · Denominator 24 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 8 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 16.13% |
2.29%
13.8 pts worse
|
Numerator 5 · Denominator 31 · Adjusted rate 15.02% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 34.26% |
8.2%
26.1 pts better
|
Numerator 37 · Denominator 108 |
| Staff flu vaccination coverage | 36.84% |
42%
5.2 pts worse
|
Numerator 42 · Denominator 114 |
| Discharge function score | 45.83% |
56.45%
10.6 pts worse
|
Numerator 11 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.5% |
89.9%
21.4 pts worse
|
93.4%
24.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.4% · Q2 68.2% · Q3 71.2% · Q4 59.0% · 4Q avg 68.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.0% |
94.5%
5.5 pts worse
|
95.5%
6.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 3.4% · Q4 6.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
11.8%
11.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
6.2%
4.3 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 10.5% · Q3 14.5% · Q4 5.2% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
32.2%
6.7 pts better
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 26.2% · Q3 25.0% · Q4 27.1% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
18.1%
3.9 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.5% · Q3 17.9% · Q4 15.0% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.1%
0.3 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.2% |
19.9%
5.3 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 33.6% · Q3 23.0% · Q4 13.4% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
15.3%
10.6 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 28.8% · Q3 32.1% · Q4 29.3% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.9%
2.7 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.6% · Q3 2.2% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.9%
1.1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
20.2%
5.5 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 30.3% · Q3 5.3% · Q4 9.2% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 13.4% |
5.4%
8 pts worse
|
5.1%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 17.6% · Q3 15.9% · Q4 14.2% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.0% |
79.6%
51.6 pts worse
|
81.7%
53.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 46.9% · Q3 22.5% · Q4 9.6% · 4Q avg 28.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
11.2%
3 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 16.7% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.6%
0.7 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.0% |
79.8%
41.8 pts worse
|
79.7%
41.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
22.2%
3.1 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 23.3% · Expected 29.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2024-08-21
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-11-04 · Fire 2021-11-04
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-19
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 2025-11-21
D · Potential for more than minimal harm
2025-11-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-21
D · Potential for more than minimal harm
2024-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
F · Potential for more than minimal harm
2021-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-10
E · Potential for more than minimal harm
2021-11-04
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 2021-12-10
D · Potential for more than minimal harm
2021-11-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-12-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-11-19
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 2025-12-09
D · Potential for more than minimal harm
2025-11-19
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 2025-12-04
D · Potential for more than minimal harm
2025-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-09
E · Potential for more than minimal harm
2024-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
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 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-20
J · Immediate jeopardy
2024-05-03
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 2024-05-23
J · Immediate jeopardy
2024-05-03
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 2024-05-23
J · Immediate jeopardy
2024-05-03
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 2024-05-23
D · Potential for more than minimal harm
2024-05-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-03
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 2024-05-23
G · Actual harm
2021-11-04
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 2021-07-15
F · Potential for more than minimal harm
2021-11-04
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 2021-12-06
F · Potential for more than minimal harm
2021-11-04
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-04
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 2021-12-06
E · Potential for more than minimal harm
2021-11-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-19
D · Potential for more than minimal harm
2021-11-04
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 2021-12-06
D · Potential for more than minimal harm
2021-11-04
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 2021-12-06
D · Potential for more than minimal harm
2021-11-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-11-04
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 2021-12-06
Penalties and ownership
What sits behind the stars
$9,062
2024-05-03
Fine
Fine · fine $9,062
Fine
Ownership
Daniel, Anton
Operational/Managerial Control · Individual
Herskowitz, David
Operational/Managerial Control · Individual
Norris, John
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Cumberland Village Care
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4-star overall rating with 4-star inspections with $18,769 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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