Cycle 1
Health 2024-02-06 · Fire 2024-02-06
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Etowah, TN
Starr Regional Health & Rehabilitation
3-star overall rating with 3-star inspections with $8,697 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
886 Hwy 411 North, Etowah, TN
(423) 263-3646
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
88
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifepoint Health
Operator or chain grouping
Approved since
1992-03-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 4 overall / 4 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
0.82
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,304
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.34
Composite VBP score used to determine payment impact.
Payment multiplier
1.0045
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.25
Baseline 17.94% · Performance 17.61% · Measure score 8.25 · Achievement 8.25 · Improvement 3.13
Healthcare-associated infections
3.73
Baseline 5.26% · Performance 6.72% · Measure score 3.73 · Achievement 3.73 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.13
Baseline 3.35 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 2.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 93 · Observed rate 9.68% · Lower 95% interval 7.88% |
| Discharge to community | 59.76% |
50.57%
9.2 pts better
|
Better than the National Rate · Eligible stays 77 · Observed rate 61.04% · Lower 95% interval 51.14% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 51.28% |
53.69%
2.4 pts worse
|
Numerator 20 · Denominator 39 |
| Discharge mobility score | 56.41% |
50.94%
5.5 pts better
|
Numerator 22 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 4 · Denominator 88 |
| Staff flu vaccination coverage | 43.37% |
42%
1.4 pts better
|
Numerator 36 · Denominator 83 |
| Discharge function score | 58.97% |
56.45%
2.5 pts better
|
Numerator 23 · Denominator 39 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.58% |
25.2%
2.6 pts worse
|
Numerator 7 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.9%
9.6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.5%
3.6 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.2% |
3.6%
6.6 pts worse
|
3.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 11.5% · Q3 10.2% · Q4 4.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
11.8%
10.2 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 4.1% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
6.2%
4.6 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 13.9% · Q3 8.3% · Q4 12.1% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.4% |
32.2%
0.2 pts worse
|
19.6%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 35.1% · Q3 29.7% · Q4 29.4% · 4Q avg 32.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.3% |
18.1%
1.2 pts worse
|
16.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 20.6% · Q3 15.6% · Q4 15.6% · 4Q avg 19.3% · 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 | 21.4% |
19.9%
1.5 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
15.3%
2.9 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 9.4% · Q3 22.9% · Q4 12.5% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.9%
1.7 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 0.0% · Q3 4.2% · Q4 2.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
20.2%
1.5 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 21.8% · Q3 20.9% · Q4 4.6% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.4%
2.2 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.4% · Q3 2.4% · Q4 4.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
79.6%
18.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 97.1% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.2%
5.2 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.6%
0.6 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
79.8%
18.8 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.2%
2 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.5% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-23 · Fire 2021-06-23
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-04
F · Potential for more than minimal harm
2019-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-02-06
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-04
E · Potential for more than minimal harm
2021-06-23
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 2021-07-16
D · Potential for more than minimal harm
2021-06-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-16
D · Potential for more than minimal harm
2021-06-23
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 2021-07-16
D · Potential for more than minimal harm
2021-06-23
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 2021-07-16
Penalties and ownership
What sits behind the stars
$4,017
2024-02-06
Fine
Fine · fine $4,017
Fine
$4,680
2024-02-06
Fine
Fine · fine $4,680
Fine
Ownership
Lifepoint Holdings 2 LLC
5% Or Greater Direct Ownership Interest · Organization
Coe, Sharon
Operational/Managerial Control · Individual
Davis, Daniel
Corporate Officer · Individual
Dsb Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Grooms, John
Corporate Officer · Individual
Haugh, William
Corporate Officer · Individual
Historic Lifepoint Hospitals, LLC
5% Or Greater Indirect Ownership Interest · Organization
Hudgins, Crystal
Operational/Managerial Control · Individual
Lapinski, Evan
Operational/Managerial Control · Individual
Lawrence, Charlotte
Corporate Officer · Individual
Legacy Lifepoint Health LLC
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Corporate Services General Partnership
Operational/Managerial Control · Organization
Lifepoint Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Lifepoint Hospitals Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Masengil, Elizabeth
Operational/Managerial Control · Individual
Mclain, John
Operational/Managerial Control · Individual
Mills, Emily
Operational/Managerial Control · Individual
Monte, Christopher
Corporate Officer · Individual
Poppell, Marcus
Corporate Officer · Individual
Roberts, Patricia
Operational/Managerial Control · Individual
Stutts, Wallace
Operational/Managerial Control · Individual
Watson, Georgette
Operational/Managerial Control · Individual
Wilson, Shelby
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Etowah Health And Rehabilitation
Etowah, TN
2-star overall rating with 2-star inspections with $21,692 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Nhc Healthcare, Athens
Athens, TN
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Life Care Center Of Athens
Athens, TN
5-star overall rating with 5-star inspections with 6 fire-safety deficiencies in the latest cycle
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