Cycle 1
Health 2022-10-27 · Fire 2022-10-27
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
Arabella Health & Wellness Of Birmingham
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1028 Bessemer Rd, Birmingham, AL
(205) 923-1777
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
163
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Arabella Healthcare Management
Operator or chain grouping
Approved since
1973-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 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
0.62
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,010
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 76.42% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.80
Baseline 3.20 hours · Performance 3.59 hours · Measure score 1.80 · Achievement 1.80 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 28.57% |
95.27%
66.7 pts worse
|
Numerator 8 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18.27% |
8.2%
10.1 pts better
|
Numerator 19 · Denominator 104 |
| Staff flu vaccination coverage | 13.64% |
42%
28.4 pts worse
|
Numerator 12 · Denominator 88 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · 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 | 14.29% |
25.2%
10.9 pts worse
|
Numerator 3 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.3%
8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.8% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
94.8%
2.3 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 pts better
|
Long 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 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 | 5.3% |
5.3%
About the same
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.2% · Q3 4.5% · Q4 5.7% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
24.9%
0.9 pts better
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 30.5% · Q3 19.7% · Q4 19.1% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
22.8%
6.5 pts better
|
16.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 13.5% · Q3 14.6% · Q4 21.2% · 4Q avg 16.3% · 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 | 5.8% |
14.8%
9 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
13.4%
9.9 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 6.2% · Q3 1.8% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.5% |
13.5%
4 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.4% · Q3 9.0% · Q4 5.6% · 4Q avg 9.5% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
5.7%
5.2 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.6% · Q3 13.2% · Q4 14.6% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
84.3%
15.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.0% |
11.5%
7.5 pts worse
|
12.0%
7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 25.0% · Expected 14.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
2.1%
3.5 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 8.3% · Q4 6.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
80.3%
4.9 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.4% |
24.5%
13.9 pts worse
|
23.9%
14.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.4% · Observed 50.0% · Expected 31.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-12 · Fire 2019-12-12
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-10-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-07
F · Potential for more than minimal harm
2022-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-07
D · Potential for more than minimal harm
2022-10-27
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 2022-12-07
D · Potential for more than minimal harm
2022-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-16
D · Potential for more than minimal harm
2022-10-27
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 2022-11-16
F · Potential for more than minimal harm
2019-12-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-22
E · Potential for more than minimal harm
2019-12-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-01-22
D · Potential for more than minimal harm
2018-11-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2018-12-11
D · Potential for more than minimal harm
2018-11-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-12-11
D · Potential for more than minimal harm
2018-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-11
D · Potential for more than minimal harm
2018-11-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-10-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-10-27
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 2022-12-02
D · Potential for more than minimal harm
2019-12-12
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 2020-01-20
D · Potential for more than minimal harm
2019-12-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-01-20
D · Potential for more than minimal harm
2019-12-12
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 2020-01-20
D · Potential for more than minimal harm
2019-12-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-01-20
F · Potential for more than minimal harm
2018-11-01
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 2018-12-06
D · Potential for more than minimal harm
2018-11-01
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 2018-12-06
D · Potential for more than minimal harm
2018-11-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-12-06
D · Potential for more than minimal harm
2018-11-01
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 2018-12-06
D · Potential for more than minimal harm
2018-11-01
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 2018-12-06
C · Minimal harm
2018-11-01
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-12-06
Penalties and ownership
What sits behind the stars
Ownership
Arabella Al 600 Opco LP
5% Or Greater Direct Ownership Interest · Organization
Arabella Health & Wellness Of Bessemer Propco LLC
5% Or Greater Mortgage Interest · Organization
Arabella Healthcare Management LLC
Operational/Managerial Control · Organization
Arco Kano Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Azzam, Mohannad
Operational/Managerial Control · Individual
Gnh Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Hertzel, Chaim
Operational/Managerial Control · Individual
Hertzel, Chaim
Corporate Officer · Individual
Hwood Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Selman, Sydney
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Arlington Rehabilitation & Healthcare Center
Birmingham, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Caregivers Of Pleasant Grove, Inc
Pleasant Grove, AL
1-star overall rating with 2-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Legacy Health And Rehabilitation Of Pleasant Grove
Pleasant Grove, AL
1-star overall rating with 1-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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