Cycle 1
Health 2024-06-26 · Fire 2024-06-26
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Birmingham, AL
Birmingham Nursing And Rehabilitation Ctr LLC
1-star overall rating with 1-star inspections with abuse icon flag with $111,811 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1000 Dugan Avenue, Birmingham, AL
(205) 798-8780
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Norbert Bennett & Donald Denz
Operator or chain grouping
Approved since
1978-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
0.31
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,133
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
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
1.90
Baseline 49.46% · Performance 55.91% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Adjusted total nurse staffing
3.03
Baseline 2.91 hours · Performance 3.92 hours · Measure score 3.03 · Achievement 2.96 · Improvement 3.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 6.61% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 28.89% |
95.27%
66.4 pts worse
|
Numerator 13 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 52% |
53.69%
1.7 pts worse
|
Numerator 13 · Denominator 25 |
| Discharge mobility score | 32% |
50.94%
18.9 pts worse
|
Numerator 8 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 45 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.49% |
8.2%
2.7 pts worse
|
Numerator 10 · Denominator 182 |
| Staff flu vaccination coverage | 26.88% |
42%
15.1 pts worse
|
Numerator 50 · Denominator 186 |
| Discharge function score | 48% |
56.45%
8.5 pts worse
|
Numerator 12 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.3%
8.5 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.8%
4.4 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.4%
2.8 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.6% · 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 | 5.7% |
5.3%
0.4 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.6% · Q3 5.9% · Q4 3.3% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
24.9%
6.6 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 19.3% · Q3 17.3% · Q4 17.7% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
22.8%
3 pts better
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 16.9% · Q3 23.3% · Q4 23.9% · 4Q avg 19.8% · 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 | 8.9% |
14.8%
5.9 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.6% · Q3 6.1% · Q4 13.6% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
13.4%
7.7 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.7% · Q3 3.0% · Q4 9.7% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.3%
0.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.7% · Q3 0.0% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.4% · Q3 2.6% · Q4 1.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
13.5%
8.5 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.3% · Q3 7.5% · Q4 1.8% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.7%
0.3 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.9% · Q3 4.2% · Q4 4.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
84.3%
11.6 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 97.7% · Q3 100.0% · Q4 97.9% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
11.5%
4.5 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 8.3% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.1%
0.9 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
80.3%
8.6 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.7% |
24.5%
14.2 pts worse
|
23.9%
14.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.7% · Observed 41.7% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-08-16 · Fire 2023-08-16
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-01-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-25
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-01-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
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 2025-12-22
D · Potential for more than minimal harm
2025-12-04
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-22
J · Immediate jeopardy
2025-10-29
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 2025-11-27
J · Immediate jeopardy
2025-10-29
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 2025-12-22
J · Immediate jeopardy
2025-10-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-27
J · Immediate jeopardy
2025-10-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-27
J · Immediate jeopardy
2025-10-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-10-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-26
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 2025-02-07
D · Potential for more than minimal harm
2025-03-26
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-11-10
D · Potential for more than minimal harm
2024-06-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-04
E · Potential for more than minimal harm
2024-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-08-16
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 2023-09-20
F · Potential for more than minimal harm
2023-08-16
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 2023-09-20
D · Potential for more than minimal harm
2023-08-16
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 2023-09-20
D · Potential for more than minimal harm
2023-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-20
Penalties and ownership
What sits behind the stars
$105,610
2025-10-29
Fine
Fine · fine $105,610
Fine
$6,201
2023-08-16
Fine
Fine · fine $6,201
Fine
Ownership
D&N, LLC
5% Or Greater Direct Ownership Interest · Organization
Dtd Hc, LLC
5% Or Greater Direct Ownership Interest · Organization
Bennett, Norbert
5% Or Greater Indirect Ownership Interest · Individual
Denz, Donald
5% Or Greater Indirect Ownership Interest · Individual
Donad T Denz Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Griffith, Delilah
W-2 Managing Employee · Individual
Norbert A Bennett Irrv Tr Fbo Children
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Grandchildren
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Cherry Hill Rehabilitation & Healthcare Center
Birmingham, AL
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Oak Knoll Health And Rehabilitation, LLC
Birmingham, AL
2-star overall rating with 1-star inspections with $22,340 in total fines with 6 recent health deficiencies
#3
Arlington Rehabilitation & Healthcare Center
Birmingham, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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