Cycle 1
Health 2024-01-12 · Fire 2024-01-12
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Vestavia, AL
Aspire Physical Recovery Center At Cahaba River
1-star overall rating with 1-star inspections with $16,801 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3070 Healthy Way, Vestavia, AL
(205) 977-7216
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
2016-09-29
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
0.79
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.99
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,924
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.79
Baseline 22.06% · Performance 20.91% · Measure score 1.79 · Achievement 1.13 · Improvement 1.79
Healthcare-associated infections
0
Baseline 8.37% · Performance 8.67% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 67.65% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.08
Baseline 5.71 hours · Performance 4.24 hours · Measure score 4.08 · Achievement 4.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.78% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 347 · Observed rate 12.97% · Lower 95% interval 10.15% |
| Discharge to community | 57.16% |
50.57%
6.6 pts better
|
Better than the National Rate · Eligible stays 339 · Observed rate 50.74% · Lower 95% interval 50.75% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.73% |
95.27%
0.5 pts better
|
Numerator 157 · Denominator 164 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 164 |
| Discharge self-care score | 67.62% |
53.69%
13.9 pts better
|
Numerator 71 · Denominator 105 |
| Discharge mobility score | 54.29% |
50.94%
3.4 pts better
|
Numerator 57 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 164 · Adjusted rate 2.26% |
| Healthcare-associated infections requiring hospitalization | 8.67% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 205 · Observed rate 9.27% · Lower 95% interval 6.02% |
| Staff COVID-19 vaccination coverage | 0.88% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 114 |
| Staff flu vaccination coverage | 7.21% |
42%
34.8 pts worse
|
Numerator 16 · Denominator 222 |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 66 · Denominator 105 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 69 · Denominator 69 |
| Transfer of health information to patient | 97.47% |
96.28%
1.2 pts better
|
Numerator 77 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 43.68% |
25.2%
18.5 pts better
|
Numerator 38 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.0
0.8 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.8
1.4 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
91.3%
4 pts better
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 98.4% · Q3 92.6% · Q4 96.0% · 4Q avg 95.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
94.8%
1.8 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.4%
0.9 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 1.9% · Q4 2.0% · 4Q avg 2.5% · 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 | 5.1% |
5.3%
0.2 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.2% · Q3 0.0% · Q4 7.9% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.9% |
24.9%
12 pts worse
|
19.6%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 28.6% · Q3 41.9% · Q4 39.5% · 4Q avg 36.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
22.8%
3.3 pts better
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 20.9% · Q3 23.1% · Q4 15.6% · 4Q avg 19.5% · 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 | 19.7% |
14.8%
4.9 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
13.4%
8.3 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 21.4% · Q3 22.0% · Q4 11.4% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.3%
0.2 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 3.7% · Q4 2.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.0% |
13.5%
4.5 pts worse
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 23.9% · Q3 13.7% · Q4 6.8% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 12.4% |
5.7%
6.7 pts worse
|
5.1%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 9.7% · Q3 18.0% · Q4 8.2% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
84.3%
3.7 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 90.0% · Q3 86.4% · Q4 83.4% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.5%
0.4 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
2.1%
0.2 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.6% · Q3 1.8% · Q4 1.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.8% |
80.3%
4.5 pts worse
|
79.7%
3.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
24.5%
3.7 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 27.8% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-19 · Fire 2019-09-19
6 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-31
E · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-02
D · Potential for more than minimal harm
2019-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-28
F · Potential for more than minimal harm
2018-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-09-25
E · Potential for more than minimal harm
2018-08-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-09-25
Inspection history
Recent health citations
J · Immediate jeopardy
2024-01-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-10
F · Potential for more than minimal harm
2024-01-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-12
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 2024-02-19
D · Potential for more than minimal harm
2024-01-12
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-12
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 2024-02-19
D · Potential for more than minimal harm
2024-01-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-12
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 2024-02-19
F · Potential for more than minimal harm
2019-09-19
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 2019-10-24
F · Potential for more than minimal harm
2019-09-19
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-19
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 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-24
F · Potential for more than minimal harm
2018-08-16
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 2018-09-20
E · Potential for more than minimal harm
2018-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-20
D · Potential for more than minimal harm
2018-08-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-09-20
Penalties and ownership
What sits behind the stars
$16,801
2024-01-12
Fine
Fine · fine $16,801
Fine
Ownership
Northport Holding 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
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Cahaba River Health Realty, LLC
5% Or Greater Security Interest · Organization
Estes, James
Corporate Officer · Individual
Holmes, Letchernique
Operational/Managerial Control · Individual
Holmes, Letchernique
Corporate Director · Individual
Long, Phillip
Corporate Officer · Individual
Patterson, Derek
Operational/Managerial Control · Individual
Patterson, Derek
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Mortgage Interest · Organization
Wheeler, John
Operational/Managerial Control · Individual
Wheeler, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Elite Nursing And Rehabilitation Care Center
Birmingham, AL
1-star overall rating with 1-star inspections with $6,682 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brookdale University Park SNF (Al)
Birmingham, AL
1-star overall rating with 1-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Aspire Physical Recovery Center At Hoover, LLC
Hoover, AL
1-star overall rating with 1-star inspections with $15,593 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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