Cycle 1
Health 2021-04-01 · Fire 2021-04-01
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Montgomery, AL
Capitol Hill Healthcare Center
4-star overall rating with 4-star inspections with 1 recent health deficiencies
520 South Hull Street, Montgomery, AL
(334) 834-2920
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
284
Certified beds
Average residents
220
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.40
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.17
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
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,350
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.10
Baseline 20.38% · Performance 19.99% · Measure score 3.10 · Achievement 3.10 · Improvement 0.66
Healthcare-associated infections
0
Baseline 7.98% · Performance 8.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.77
Baseline 31.45% · Performance 40.11% · Measure score 5.77 · Achievement 5.77 · Improvement 0
Adjusted total nurse staffing
3.12
Baseline 4 hours · Performance 3.97 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.1% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 16.39% · Lower 95% interval 9.86% |
| Discharge to community | 46.5% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 40.16% · Lower 95% interval 37.7% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.78% |
95.27%
3.5 pts better
|
Numerator 81 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 24 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.22% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 82 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 8.11% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 9.33% · Lower 95% interval 5.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 207 |
| Staff flu vaccination coverage | 12.82% |
42%
29.2 pts worse
|
Numerator 35 · Denominator 273 |
| Discharge function score | 47.92% |
56.45%
8.5 pts worse
|
Numerator 23 · Denominator 48 |
| Transfer of health information to provider | 98.36% |
95.95%
2.4 pts better
|
Numerator 60 · Denominator 61 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 4 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.3%
6.7 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 97.5% · Q3 99.0% · Q4 98.5% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.8%
3.8 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.4%
1.5 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.5% · Q3 1.5% · Q4 1.5% · 4Q avg 1.9% · 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 0.6% · Q3 0.5% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.3%
2.3 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 10.6% · Q3 10.9% · Q4 4.9% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
24.9%
9.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 13.3% · Q3 13.0% · Q4 17.7% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
22.8%
0.6 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 23.0% · Q3 22.1% · Q4 26.9% · 4Q avg 23.4% · 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 | 9.3% |
14.8%
5.5 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 11.6% · Q3 4.1% · Q4 8.5% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
13.4%
3 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 13.1% · Q3 9.0% · Q4 10.4% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.3%
1.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 2.7% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.6%
0.2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.5% · Q3 3.6% · Q4 3.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
13.5%
2 pts worse
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 11.8% · Q3 18.0% · Q4 17.9% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
5.7%
1.5 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.6% · Q3 8.4% · Q4 7.4% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
84.3%
14.9 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.5% · Q3 99.0% · Q4 99.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.5%
5.2 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 6.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.1%
0.6 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 3.1% · Q3 4.9% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
80.3%
16.6 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.0% |
24.5%
9.5 pts worse
|
23.9%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.0% · Observed 32.3% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-02-21 · Fire 2019-02-21
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-03-29 · Fire 2018-03-29
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-02-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-04-02
E · Potential for more than minimal harm
2018-03-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-04-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-04-01
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 2021-05-06
D · Potential for more than minimal harm
2019-02-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-28
D · Potential for more than minimal harm
2018-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-03
Penalties and ownership
What sits behind the stars
Ownership
Turenne, William
5% Or Greater Direct Ownership Interest · Individual
Turenne, Roger
5% Or Greater Direct Ownership Interest · Individual
King, Robert
Operational/Managerial Control · Individual
Mcgee, Tammy
Operational/Managerial Control · Individual
Mcmillian, Virginia
Operational/Managerial Control · Individual
Turenne & Associates LLC
Operational/Managerial Control · Organization
Turenne Pharmedco Inc
Operational/Managerial Control · Organization
Walls, Emily
Corporate Officer · Individual
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#3
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