Cycle 1
Health 2021-06-09 · Fire 2021-06-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Pulaski, TN
Meadowbrook Healthcare and Rehabilitation Center
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1245 E College St, Pulaski, TN
(931) 363-7548
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2002-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing
LPN hours / resident day
0.93
Licensed practical nurse staffing
Aide hours / resident day
2.08
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.9%
9.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 81.0% |
94.5%
13.5 pts worse
|
95.5%
14.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.6%
1.8 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
11.8%
7.6 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.2%
1.1 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 64.6% |
32.2%
32.4 pts worse
|
19.6%
45 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.7% |
18.1%
7.6 pts worse
|
16.7%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.8% |
19.9%
8.9 pts worse
|
16.3%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
15.3%
2.5 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
1.9%
3.1 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
20.2%
6.3 pts worse
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.4%
1.7 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
79.6%
17.9 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
11.2%
2.8 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
79.8%
8.5 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
22.2%
9.6 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-19 · Fire 2019-06-19
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-09-06 · Fire 2018-09-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-06-09
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 2021-06-17
D · Potential for more than minimal harm
2019-06-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-03
D · Potential for more than minimal harm
2019-06-19
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-08-03
D · Potential for more than minimal harm
2019-06-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-08-03
D · Potential for more than minimal harm
2018-09-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-10-06
C · Minimal harm
2018-09-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-10-06
C · Minimal harm
2018-09-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-10-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-07-18
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-18
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 2023-08-21
D · Potential for more than minimal harm
2021-06-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-02
F · Potential for more than minimal harm
2019-06-19
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 2019-08-03
D · Potential for more than minimal harm
2019-06-19
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 2019-08-03
D · Potential for more than minimal harm
2019-06-19
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2019-08-03
Penalties and ownership
What sits behind the stars
Ownership
Rocky Top Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Albrechtsen, Tyler
Corporate Director · Individual
Albrechtsen, Tyler
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Raymer, Jennifer
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Thatcher, Brent
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Nhc Healthcare, Pulaski
Pulaski, TN
3-star overall rating with 2-star inspections with 6 recent health deficiencies
#2
Elk River Health And Nursing Center Of Ardmore, Ll
Ardmore, TN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Lawrenceburg
Lawrenceburg, TN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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