Gadsden, AL

Mcguffey Health & Rehabilitation Center

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

2301 Rainbow Drive, Gadsden, AL

(256) 543-3467

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

209

Certified beds

Average residents

166

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-12-01

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

0.56

Registered nurse staffing · state 0.64 · national 0.68

LPN hours / resident day

0.83

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.40

Nurse aide staffing · state 2.50 · national 2.35

Total nurse hours

3.80

All reported nurse hours · state 3.91 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.29

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.36 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

4.57

CMS adjusted total nurse staffing hours

Case-mix index

1.14

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,501

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

Performance score

20.15

Composite VBP score used to determine payment impact.

Payment multiplier

0.9823

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.91% · Performance 21.88% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 7.12% · Performance 7.84% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.88

Baseline 50.00% · Performance 43.71% · Measure score 4.88 · Achievement 4.88 · Improvement 2

Adjusted total nurse staffing

3.18

Baseline 4.24 hours · Performance 3.98 hours · Measure score 3.18 · Achievement 3.18 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.09%	10.72% 2.4 pts worse	No Different than the National Rate · Eligible stays 94 · Observed rate 18.09% · Lower 95% interval 8.66%
Discharge to community	47.44%	50.57% 3.1 pts worse	No Different than the National Rate · Eligible stays 85 · Observed rate 38.82% · Lower 95% interval 38.36%
Medicare spending per beneficiary	1.01	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 66 · Denominator 66
Falls with major injury	1.52%	0.77% 0.8 pts worse	Numerator 1 · Denominator 66
Discharge self-care score	48.98%	53.69% 4.7 pts worse	Numerator 24 · Denominator 49
Discharge mobility score	65.31%	50.94% 14.4 pts better	Numerator 32 · Denominator 49
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 66 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.84%	7.12% 0.7 pts worse	No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 4.09%
Staff COVID-19 vaccination coverage	8.88%	8.2% 0.7 pts better	Numerator 15 · Denominator 169
Staff flu vaccination coverage	22.65%	42% 19.4 pts worse	Numerator 53 · Denominator 234
Discharge function score	63.27%	56.45% 6.8 pts better	Numerator 31 · Denominator 49
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 41 · Denominator 41
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	12%	25.2% 13.2 pts worse	Numerator 3 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	2.0 0.6 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.8 0.7 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	91.3% 8.7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	4.1%	3.4% 0.7 pts worse	3.3% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.6% · Q3 2.6% · Q4 2.0% · 4Q avg 4.1% · 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 6.7% · Q2 7.1% · Q3 4.3% · Q4 11.9% · 4Q avg 7.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.4%	24.9% 7.5 pts better	19.6% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 17.3% · Q3 17.1% · Q4 16.7% · 4Q avg 17.4%
Percentage of long-stay residents who received an antipsychotic medication	19.8%	22.8% 3 pts better	16.7% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.4% · Q3 20.3% · Q4 23.1% · 4Q avg 19.8% · 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	24.5%	14.8% 9.7 pts worse	16.3% 8.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 19.6% · Q3 27.7% · Q4 26.0% · 4Q avg 24.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	20.6%	13.4% 7.2 pts worse	14.9% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 18.3% · Q3 26.7% · Q4 23.0% · 4Q avg 20.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.7%	1.3% 0.4 pts worse	1.0% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.3% · Q3 1.4% · Q4 0.5% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	2.6% 1.6 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.4% · Q3 0.7% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.3%	13.5% 10.8 pts worse	19.8% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 22.9% · Q3 22.1% · Q4 28.5% · 4Q avg 24.3%
Percentage of long-stay residents with pressure ulcers	8.8%	5.7% 3.1 pts worse	5.1% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.8% · Q3 11.5% · Q4 3.4% · 4Q avg 8.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	84.3% 15.7 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	11.5%	11.5% About the same	12.0% 0.5 pts better	Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.6% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.6%	2.1% 2.5 pts worse	1.6% 3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.7% · Q3 7.6% · Q4 6.3% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.9%	80.3% 18.6 pts better	79.7% 19.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	11.6%	24.5% 12.9 pts better	23.9% 12.3 pts better	Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.6% · Expected 21.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2021-05-27 · Fire 2021-05-27

2 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2020-03-12 · Fire 2020-03-12

2 health deficiencies

Top issue: Infection Control (1 deficiency)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2019-02-07 · Fire 2019-02-07

3 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2021-05-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-07-07

F · Potential for more than minimal harm 2020-03-12

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2020-10-28

E · Potential for more than minimal harm 2020-03-12

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 2020-09-23

D · Potential for more than minimal harm 2020-03-12

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2020-09-30

D · Potential for more than minimal harm 2020-03-12

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2020-10-23

E · Potential for more than minimal harm 2019-02-07

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-03-21

Inspection history

Recent health citations

D · Potential for more than minimal harm 2021-05-27

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2021-07-01

D · Potential for more than minimal harm 2021-05-27

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2021-07-01

D · Potential for more than minimal harm 2020-03-12

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 2020-04-16

D · Potential for more than minimal harm 2020-03-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-04-16

D · Potential for more than minimal harm 2019-02-07

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2019-03-14

D · Potential for more than minimal harm 2019-02-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2019-03-14

D · Potential for more than minimal harm 2019-02-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-14

Penalties and ownership