Cycle 1
Health 2022-03-17 · Fire 2022-03-17
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Huntsville, AL
Brookshire Healthcare Center
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4320 Judith Lane, Huntsville, AL
(256) 837-1730
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Venza Care Management
Operator or chain grouping
Approved since
1975-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 3 overall / 3 health / 4 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
0.78
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
5.05
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,121
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.80% · Performance 22.35% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.47% · Performance 9.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.80
Baseline 82.20% · Performance 57.52% · Measure score 3.80 · Achievement 1.51 · Improvement 3.80
Adjusted total nurse staffing
4.75
Baseline 3.53 hours · Performance 4.43 hours · Measure score 4.75 · Achievement 4.75 · Improvement 3.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.76% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 168 · Observed rate 17.26% · Lower 95% interval 10.03% |
| Discharge to community | 47.81% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 128 · Observed rate 37.5% · Lower 95% interval 37.59% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 138 · Denominator 139 |
| Falls with major injury | 2.16% |
0.77%
1.4 pts worse
|
Numerator 3 · Denominator 139 |
| Discharge self-care score | 26.25% |
53.69%
27.4 pts worse
|
Numerator 21 · Denominator 80 |
| Discharge mobility score | 38.75% |
50.94%
12.2 pts worse
|
Numerator 31 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 3.6% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 139 · Adjusted rate 2.92% |
| Healthcare-associated infections requiring hospitalization | 9.04% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 12.77% · Lower 95% interval 5.8% |
| Staff COVID-19 vaccination coverage | 7.81% |
8.2%
0.4 pts worse
|
Numerator 15 · Denominator 192 |
| Staff flu vaccination coverage | 25.79% |
42%
16.2 pts worse
|
Numerator 49 · Denominator 190 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 40 · Denominator 80 |
| Transfer of health information to provider | 96.08% |
95.95%
0.1 pts better
|
Numerator 49 · Denominator 51 |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 42 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 7.35% |
25.2%
17.9 pts worse
|
Numerator 5 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
91.3%
4.4 pts worse
|
93.4%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.3% · Q2 82.1% · Q3 89.4% · Q4 99.0% · 4Q avg 86.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.8% |
94.8%
11 pts worse
|
95.5%
11.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.4%
1.5 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.3% · Q3 6.4% · Q4 4.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
1.3%
1 pts worse
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.3% · Q3 1.2% · Q4 1.1% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.3%
3.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.5% · Q4 3.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
24.9%
14.5 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 9.8% · Q3 8.4% · Q4 8.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.9% |
22.8%
7.1 pts worse
|
16.7%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 32.8% · Q3 29.0% · Q4 30.6% · 4Q avg 29.9% · 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 | 22.6% |
14.8%
7.8 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 30.7% · Q3 22.6% · Q4 22.0% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
13.4%
13.6 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 38.5% · Q3 17.7% · Q4 29.6% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 3.3% · Q4 1.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.9% |
13.5%
2.4 pts worse
|
19.8%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 21.4% · Q3 11.9% · Q4 18.5% · 4Q avg 15.9% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.7%
1.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.7% · Q3 4.9% · Q4 2.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.5% |
84.3%
20.8 pts worse
|
81.7%
18.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 57.9% · Q3 76.6% · Q4 91.0% · 4Q avg 63.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
11.5%
8.2 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 20.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.1%
0.7 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 1.1% · Q4 2.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.5% |
80.3%
11.8 pts worse
|
79.7%
11.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
24.5%
4.7 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 21.2% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-21 · Fire 2019-05-21
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-05-24 · Fire 2018-05-24
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-03-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-04
E · Potential for more than minimal harm
2022-03-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-03-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-03-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-03-17
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 2022-04-04
D · Potential for more than minimal harm
2019-05-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-06-10
D · Potential for more than minimal harm
2019-05-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-28
C · Minimal harm
2019-05-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-05-30
E · Potential for more than minimal harm
2018-05-24
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 2018-06-30
C · Minimal harm
2018-05-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-06-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-03-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-17
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 2022-04-19
D · Potential for more than minimal harm
2022-03-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-17
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 2022-04-19
D · Potential for more than minimal harm
2019-05-21
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 2019-06-22
D · Potential for more than minimal harm
2019-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-22
D · Potential for more than minimal harm
2018-05-24
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 2018-06-23
Penalties and ownership
What sits behind the stars
Ownership
Aop SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Aop Opco Manager LLC
Operational/Managerial Control · Organization
Ch Aop Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Cody, Brenda
Operational/Managerial Control · Individual
Goodman, Menucha
Operational/Managerial Control · Individual
Goodman, Menucha
Corporate Officer · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
M Melb Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
M Melb Opco Trust
5% Or Greater Indirect Ownership Interest · Organization
Melb Opco Manager LLC
Operational/Managerial Control · Organization
Ms Aop Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
S Melb Opco Trust
5% Or Greater Indirect Ownership Interest · Organization
Ss Aop Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Vertex Financial Services LLC
Operational/Managerial Control · Organization
Wagner, John
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Windsor House
Huntsville, AL
1-star overall rating with 1-star inspections with $266,231 in total fines with 11 recent health deficiencies
#2
Diversicare Of Big Springs
Huntsville, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
The Health Center At Research Park
Huntsville, AL
1-star overall rating with 1-star inspections with abuse icon flag with $69,011 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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