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
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.72
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.08
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
1.65
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
0.42
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,498
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.17
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 21.15% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.74
Baseline 8.37% · Performance 6.94% · Measure score 3.74 · Achievement 3 · Improvement 3.74
Total nurse turnover
4.33
Baseline 48.78% · Performance 46.00% · Measure score 4.33 · Achievement 4.33 · Improvement 0.66
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 11.29% · Lower 95% interval 7.67% |
| Discharge to community | 45.33% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 40.32% · Lower 95% interval 35.27% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 3 · Denominator 36 · Adjusted rate 6.62% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 12.94% |
42%
29.1 pts worse
|
Numerator 11 · Denominator 85 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · 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 |
|---|---|---|---|---|
| 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 · Q1 100.0% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 · 4Q avg 81.0% |
| 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 · Q1 0.0% · Q2 1.8% · Q3 3.6% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 6.2% · Q2 0.0% · Q3 1.9% · Q4 8.5% · 4Q avg 4.2% |
| 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 · Q1 8.5% · Q2 12.2% · Q3 6.7% · Q4 2.3% · 4Q avg 7.3% |
| 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 · Q1 60.4% · Q2 65.9% · Q3 62.2% · Q4 70.5% · 4Q avg 64.6% |
| 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 · Q1 31.4% · Q2 25.0% · Q4 24.2% · 4Q avg 25.7% · 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 | 28.8% |
19.9%
8.9 pts worse
|
16.3%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 57.8% · 4Q avg 28.8% · Used in QM five-star |
| 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 · Q1 41.9% · Q2 16.7% · Q3 5.1% · Q4 5.1% · 4Q avg 17.8% · Used in QM five-star |
| 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 · Q1 1.3% · Q2 0.0% · Q3 2.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 11.9% · Q2 1.9% · Q3 3.6% · Q4 1.9% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 21.2% · Q2 29.5% · Q3 26.7% · Q4 29.6% · 4Q avg 26.5% |
| 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 · Q1 6.1% · Q2 3.6% · Q3 2.9% · Q4 2.0% · 4Q avg 3.7% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 94.9% · Q3 94.8% · Q4 100.0% · 4Q avg 97.5% |
| 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 · Adjusted 14.0% · Observed 13.5% · Expected 10.8% · 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 | 88.3% |
79.8%
8.5 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| 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 · Adjusted 31.8% · Observed 32.4% · Expected 24.3% · Used in QM five-star |
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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