Cycle 1
Health 2022-04-13 · Fire 2022-04-13
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Goodlettsville, TN
Stoneridge Health Care, LLC
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
5121 Greer Road, Goodlettsville, TN
(615) 859-5895
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
38
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-06-26
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
0.93
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.29
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 7.69% · Lower 95% interval 6.24% |
| Discharge to community | 48.06% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 40.74% · Lower 95% interval 34.18% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 91.3% |
95.27%
4 pts worse
|
Numerator 21 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| 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 | 4.35% |
2.29%
2.1 pts worse
|
Numerator 1 · Denominator 23 · Adjusted rate 3.53% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 47.22% |
8.2%
39 pts better
|
Numerator 17 · Denominator 36 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| 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 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 14.8% |
89.9%
75.1 pts worse
|
93.4%
78.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q3 13.6% · Q4 3.8% · 4Q avg 14.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 73.9% |
94.5%
20.6 pts worse
|
95.5%
21.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.5% · Q4 3.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
11.8%
9.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.2%
0.5 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.9% |
32.2%
0.7 pts worse
|
19.6%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 25.0% · Q4 30.4% · 4Q avg 32.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 39.1% |
18.1%
21 pts worse
|
16.7%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.1% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.6% |
19.9%
19.7 pts worse
|
16.3%
23.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.5% |
15.3%
12.2 pts worse
|
14.9%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 23.8% · 4Q avg 27.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
0.9%
3.6 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q3 0.0% · Q4 0.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.4% |
1.9%
7.5 pts worse
|
1.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q3 9.5% · Q4 12.5% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
20.2%
0.3 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 28.2% · Q4 19.8% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.4%
About the same
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q3 0.0% · Q4 10.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.6% |
79.6%
62 pts worse
|
81.7%
64.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.3% · Q2 18.9% · Q3 2.6% · Q4 0.0% · 4Q avg 17.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.2%
11.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.8% |
1.6%
6.2 pts worse
|
1.6%
6.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 37.8% |
79.8%
42 pts worse
|
79.7%
41.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 37.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
22.2%
4.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.0% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-30 · Fire 2019-05-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-04-25 · Fire 2018-04-25
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-04-13
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-07
D · Potential for more than minimal harm
2022-04-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-07
D · Potential for more than minimal harm
2019-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-14
D · Potential for more than minimal harm
2019-05-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-14
D · Potential for more than minimal harm
2019-05-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-07-14
D · Potential for more than minimal harm
2019-05-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-07-14
D · Potential for more than minimal harm
2019-05-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-14
D · Potential for more than minimal harm
2019-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-14
D · Potential for more than minimal harm
2018-04-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-06-01
D · Potential for more than minimal harm
2018-04-25
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 2018-06-01
D · Potential for more than minimal harm
2018-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-08
D · Potential for more than minimal harm
2018-04-25
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2018-06-18
D · Potential for more than minimal harm
2018-04-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2018-06-01
D · Potential for more than minimal harm
2018-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-18
C · Minimal harm
2018-04-25
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-06-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-01-31
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-31
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-31
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-02-21
F · Potential for more than minimal harm
2022-04-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-27
F · Potential for more than minimal harm
2022-04-13
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-05-27
F · Potential for more than minimal harm
2022-04-13
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 2022-05-27
E · Potential for more than minimal harm
2022-04-13
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 2022-05-27
D · Potential for more than minimal harm
2022-04-13
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 2022-05-27
D · Potential for more than minimal harm
2022-04-13
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-05-27
D · Potential for more than minimal harm
2019-05-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-30
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 2019-07-03
D · Potential for more than minimal harm
2019-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-03
D · Potential for more than minimal harm
2018-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-24
C · Minimal harm
2018-04-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2018-05-24
Penalties and ownership
What sits behind the stars
Ownership
Pierce, Sidney
5% Or Greater Direct Ownership Interest · Individual
Pierce, Sidney
Corporate Officer · Individual
Pulley, Janet
W-2 Managing Employee · Individual
Nearby options
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
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