Cycle 1
Health 2022-11-03 · Fire 2022-11-03
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Tallassee, AL
Tallassee Health And Rehabilitation, LLC
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
2639 Gilmer Avenue, Tallassee, AL
(334) 283-3975
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1976-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 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
0.60
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.37
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.49% · Performance 22.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.51
Baseline 7.94% · Performance 7.38% · Measure score 1.51 · Achievement 1.51 · Improvement 1.39
Total nurse turnover
2.35
Performance 54.05% · Measure score 2.35 · Achievement 2.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.87
Baseline 3.96 hours · Performance 4.18 hours · Measure score 3.87 · Achievement 3.87 · Improvement 0.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.1% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 10.61% · Lower 95% interval 6.9% |
| Discharge to community | 45.44% |
50.57%
5.1 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 34.04% · Lower 95% interval 29.26% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 1 · Denominator 25 · Adjusted rate 3.58% |
| Healthcare-associated infections requiring hospitalization | 7.38% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | 0.71% |
42%
41.3 pts worse
|
Numerator 1 · Denominator 140 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
91.3%
7.9 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 97.9% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.6% |
94.8%
5.2 pts worse
|
95.5%
5.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.4%
1.5 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.2% · Q4 4.2% · 4Q avg 1.9% · 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 | 1.9% |
5.3%
3.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.8% · Q3 0.0% · Q4 2.4% · 4Q avg 1.9% |
| 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 16.1% · Q2 16.0% · Q3 16.5% · Q4 20.9% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.7% |
22.8%
5.9 pts worse
|
16.7%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 32.7% · Q3 27.9% · Q4 21.1% · 4Q avg 28.7% · 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 | 9.0% |
14.8%
5.8 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 7.4% · Q3 3.7% · Q4 0.0% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
13.4%
8.4 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.7% · Q3 2.8% · Q4 6.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.1% |
13.5%
9.4 pts better
|
19.8%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.3% · Q3 2.2% · Q4 7.1% · 4Q avg 4.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.7%
2.5 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 7.6% · Q3 7.3% · Q4 7.5% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
84.3%
13 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.4% · Q3 95.0% · Q4 97.1% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.5%
1.4 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 15.4% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
2.1%
0.1 pts better
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.7% |
80.3%
7.4 pts better
|
79.7%
8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.0% |
24.5%
13.5 pts worse
|
23.9%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.0% · Observed 41.0% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-17 · Fire 2019-10-17
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-15 · Fire 2018-11-15
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-14
F · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-14
F · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-14
E · Potential for more than minimal harm
2022-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
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 2022-12-14
D · Potential for more than minimal harm
2022-11-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-14
E · Potential for more than minimal harm
2019-10-17
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-11-26
E · Potential for more than minimal harm
2019-10-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-26
F · Potential for more than minimal harm
2018-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-01-01
E · Potential for more than minimal harm
2018-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-01
E · Potential for more than minimal harm
2018-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-01
D · Potential for more than minimal harm
2018-11-15
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 2019-01-01
D · Potential for more than minimal harm
2018-11-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-01-01
D · Potential for more than minimal harm
2018-11-15
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2019-01-01
D · Potential for more than minimal harm
2018-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-06-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-07-13
F · Potential for more than minimal harm
2022-11-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-03
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 2022-12-08
D · Potential for more than minimal harm
2022-11-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-03
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-12-08
D · Potential for more than minimal harm
2019-10-17
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 2019-11-21
Penalties and ownership
What sits behind the stars
Ownership
Millennium Health Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Baggett, Bryan
Operational/Managerial Control · Individual
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Nettles, Cameronesha
Operational/Managerial Control · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Richburg, Julie
Operational/Managerial Control · Individual
Tallassee Health Realty LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
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Wetumpka Health And Rehabilitation, LLC
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1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Magnolia Haven Health And Rehabilitation Center
Tuskegee, AL
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Dadeville Healthcare Center
Dadeville, AL
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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