Cycle 1
Health 2022-04-14 · Fire 2022-04-14
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Athens, AL
Athens Health And Rehabilitation LLC
4-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
611 West Market Street, Athens, AL
(256) 232-1620
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
149
Certified beds
Average residents
138
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1967-01-01
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
0.59
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,416
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0120
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.43
Baseline 17.86% · Performance 17.99% · Measure score 7.43 · Achievement 7.43 · Improvement 0
Healthcare-associated infections
8.84
Baseline 5.63% · Performance 5.19% · Measure score 8.84 · Achievement 8.84 · Improvement 6.40
Total nurse turnover
2.99
Performance 51.46% · Measure score 2.99 · Achievement 2.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.48
Baseline 3.33 hours · Performance 4.07 hours · Measure score 3.48 · Achievement 3.48 · Improvement 2.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 484 · Observed rate 9.71% · Lower 95% interval 8.96% |
| Discharge to community | 63.3% |
50.57%
12.7 pts better
|
Better than the National Rate · Eligible stays 442 · Observed rate 63.8% · Lower 95% interval 59.61% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.04% |
95.27%
0.8 pts better
|
Numerator 267 · Denominator 278 |
| Falls with major injury | 2.16% |
0.77%
1.4 pts worse
|
Numerator 6 · Denominator 278 |
| Discharge self-care score | 47.13% |
53.69%
6.6 pts worse
|
Numerator 82 · Denominator 174 |
| Discharge mobility score | 44.25% |
50.94%
6.7 pts worse
|
Numerator 77 · Denominator 174 |
| Pressure ulcers or injuries, new or worsened | 2.52% |
2.29%
0.2 pts worse
|
Numerator 7 · Denominator 278 · Adjusted rate 2.89% |
| Healthcare-associated infections requiring hospitalization | 5.19% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 273 · Observed rate 2.93% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 8.33% |
8.2%
0.1 pts better
|
Numerator 11 · Denominator 132 |
| Staff flu vaccination coverage | 19.39% |
42%
22.6 pts worse
|
Numerator 38 · Denominator 196 |
| Discharge function score | 44.25% |
56.45%
12.2 pts worse
|
Numerator 77 · Denominator 174 |
| Transfer of health information to provider | 93.22% |
95.95%
2.7 pts worse
|
Numerator 55 · Denominator 59 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 170 · Denominator 187 |
| Resident COVID-19 vaccinations up to date | 12.98% |
25.2%
12.2 pts worse
|
Numerator 17 · Denominator 131 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
91.3%
1.9 pts better
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 94.9% · Q3 92.6% · Q4 92.6% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
94.8%
4.2 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.4%
0.5 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.0% · Q3 3.2% · Q4 2.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
1.3%
1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.3%
1.2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.1% · Q3 5.3% · Q4 2.6% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.1% |
24.9%
3.2 pts worse
|
19.6%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 26.8% · Q3 29.9% · Q4 27.3% · 4Q avg 28.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.3% |
22.8%
2.5 pts better
|
16.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 27.4% · Q3 12.1% · Q4 19.3% · 4Q avg 20.3% · 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 | 15.0% |
14.8%
0.2 pts worse
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 24.1% · Q3 12.6% · Q4 15.6% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.9% |
13.4%
4.5 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 27.2% · Q3 10.7% · Q4 13.3% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.3%
0.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.7% · Q3 0.6% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
13.5%
7 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 30.0% · Q3 19.1% · Q4 15.6% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.7%
0.9 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 12.0% · Q3 4.7% · Q4 3.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
84.3%
2.4 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 83.0% · Q3 85.1% · Q4 88.9% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.5%
3.7 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.1%
1.5 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.6% · Q4 0.5% · 4Q avg 0.6% · 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 | 19.0% |
24.5%
5.5 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.4% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-29 · Fire 2019-08-29
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2018-07-19 · Fire 2018-07-19
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-04-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-16
E · Potential for more than minimal harm
2019-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-09
E · Potential for more than minimal harm
2019-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-10
E · Potential for more than minimal harm
2019-08-29
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 2019-10-09
E · Potential for more than minimal harm
2019-08-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-09
D · Potential for more than minimal harm
2019-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-09
D · Potential for more than minimal harm
2018-07-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-08-06
C · Minimal harm
2018-07-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2019-08-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2019-10-14
D · Potential for more than minimal harm
2019-08-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-10-14
D · Potential for more than minimal harm
2019-08-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-14
D · Potential for more than minimal harm
2019-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-14
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-31
Penalties and ownership
What sits behind the stars
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
Best Health, LLC
5% Or Greater Security Interest · Organization
Cox, Tammy
Operational/Managerial Control · Individual
Cox, Tammy
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Lawrence, Hunter
Operational/Managerial Control · Individual
Lawrence, Hunter
W-2 Managing Employee · Individual
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Ward, Sonny
Operational/Managerial Control · Individual
Ward, Sonny
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Limestone Nursing And Rehabilitation Center, LLC
Athens, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies
#2
Valley View Health And Rehabilitation, LLC
Madison, AL
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
River City Center
Decatur, AL
1-star overall rating with 1-star inspections with 6 recent health deficiencies
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