Cycle 1
Health 2021-05-13 · Fire 2021-05-13
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Trussville, AL
Cavalier Healthcare Of Trussville
2-star overall rating with 3-star inspections with $46,797 in total fines with 2 recent health deficiencies
119 Watterson Parkway, Trussville, AL
(205) 655-3226
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cavalier Healthcare
Operator or chain grouping
Approved since
2016-08-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 2 overall / 3 health / 3 staffing / 4 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
0.20
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
0.62
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,453
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.92
Baseline 22.18% · Performance 21.45% · Measure score 0.92 · Achievement 0 · Improvement 0.92
Healthcare-associated infections
6.16
Baseline 8.82% · Performance 6.27% · Measure score 6.16 · Achievement 5.23 · Improvement 6.16
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.5% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 6.25% · Lower 95% interval 6.21% |
| Discharge to community | 67.01% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 100 · Observed rate 60% · Lower 95% interval 55.89% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.36% |
95.27%
1.1 pts better
|
Numerator 53 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 25% |
53.69%
28.7 pts worse
|
Numerator 11 · Denominator 44 |
| Discharge mobility score | 29.55% |
50.94%
21.4 pts worse
|
Numerator 13 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 3.11% |
| Staff COVID-19 vaccination coverage | 39.1% |
8.2%
30.9 pts better
|
Numerator 52 · Denominator 133 |
| Staff flu vaccination coverage | 10.77% |
42%
31.2 pts worse
|
Numerator 14 · Denominator 130 |
| Discharge function score | 31.82% |
56.45%
24.6 pts worse
|
Numerator 14 · Denominator 44 |
| Transfer of health information to provider | 94.29% |
95.95%
1.7 pts worse
|
Numerator 33 · Denominator 35 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 94.44% |
25.2%
69.2 pts better
|
Numerator 34 · Denominator 36 |
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 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
91.3%
2.2 pts better
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 100.0% · Q3 81.5% · Q4 97.6% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.6% |
94.8%
5.2 pts worse
|
95.5%
5.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| 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 2.2% · Q2 3.4% · Q3 4.9% · Q4 1.2% · 4Q avg 2.9% · 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 | 4.9% |
5.3%
0.4 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 4.3% · Q3 1.6% · Q4 1.6% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
24.9%
2.4 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 26.4% · Q3 32.8% · Q4 27.4% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
22.8%
6.1 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.2% · Q3 13.8% · Q4 12.7% · 4Q avg 16.7% · 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 | 17.8% |
14.8%
3 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 17.9% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
13.4%
3.8 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.2% · Q3 13.0% · Q4 13.7% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.3%
0.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.6%
0.2 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 3.7% · Q4 3.7% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.9% |
13.5%
3.4 pts worse
|
19.8%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 25.5% · Q3 11.8% · Q4 6.8% · 4Q avg 16.9% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.7%
1.4 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 5.6% · Q3 7.2% · Q4 5.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
84.3%
7.9 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 83.6% · Q4 87.1% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
11.5%
1.2 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.5% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
2.1%
0.4 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.4% · Q4 5.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
80.3%
15.3 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
24.5%
5.3 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 25.4% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-11 · Fire 2019-04-11
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-05-03 · Fire 2018-05-03
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-04-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-05-21
F · Potential for more than minimal harm
2019-04-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-21
F · Potential for more than minimal harm
2018-05-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-05-09
F · Potential for more than minimal harm
2018-05-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-05-25
E · Potential for more than minimal harm
2018-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-11
E · Potential for more than minimal harm
2018-05-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-06-06
D · Potential for more than minimal harm
2018-05-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-05-11
D · Potential for more than minimal harm
2018-05-03
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 2018-05-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-06-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-12
D · Potential for more than minimal harm
2021-05-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-06
D · Potential for more than minimal harm
2021-05-13
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 2021-06-06
D · Potential for more than minimal harm
2019-04-11
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 2019-05-16
D · Potential for more than minimal harm
2019-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-05-16
D · Potential for more than minimal harm
2019-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-28
F · Potential for more than minimal harm
2018-05-03
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 2018-06-07
D · Potential for more than minimal harm
2018-05-03
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 2018-06-07
D · Potential for more than minimal harm
2018-05-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-06-07
D · Potential for more than minimal harm
2018-05-03
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 2018-06-07
Penalties and ownership
What sits behind the stars
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,434
2024-01-22
Fine
Fine · fine $14,434
Fine
$4,178
2024-01-08
Fine
Fine · fine $4,178
Fine
$3,529
2024-01-02
Fine
Fine · fine $3,529
Fine
$8,469
2023-12-11
Fine
Fine · fine $8,469
Fine
$2,117
2023-06-26
Fine
Fine · fine $2,117
Fine
$4,194
2023-06-05
Fine
Fine · fine $4,194
Fine
Ownership
Hubbard, Brien
5% Or Greater Direct Ownership Interest · Individual
Hubbard, Brien
Operational/Managerial Control · Individual
Hubbard, Brien
Corporate Officer · Individual
Venezia, Nicolas
W-2 Managing Employee · Individual
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#3
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