Cycle 1
Health 2022-03-31 · Fire 2022-03-31
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Scottsboro, AL
Cloverdale Rehabilitation And Nursing Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
412 Cloverdale Road, Scottsboro, AL
(256) 259-1505
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
141
Certified beds
Average residents
119
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trinity Management, Inc.
Operator or chain grouping
Approved since
1977-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 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
0.55
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,178
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.19% · Performance 22.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.01
Baseline 6.64% · Performance 5.74% · Measure score 7.01 · Achievement 7.01 · Improvement 4.98
Total nurse turnover
4.79
Baseline 37.74% · Performance 44.09% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Adjusted total nurse staffing
4.61
Baseline 4.40 hours · Performance 4.39 hours · Measure score 4.61 · Achievement 4.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 8.72% · Lower 95% interval 7.27% |
| Discharge to community | 44.29% |
50.57%
6.3 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 40% · Lower 95% interval 35.63% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.35% |
95.27%
0.1 pts better
|
Numerator 82 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 54.24% |
53.69%
0.6 pts better
|
Numerator 32 · Denominator 59 |
| Discharge mobility score | 45.76% |
50.94%
5.2 pts worse
|
Numerator 27 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 2.7% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 159 |
| Staff flu vaccination coverage | 16.75% |
42%
25.2 pts worse
|
Numerator 34 · Denominator 203 |
| Discharge function score | 54.24% |
56.45%
2.2 pts worse
|
Numerator 32 · Denominator 59 |
| Transfer of health information to provider | 89.29% |
95.95%
6.7 pts worse
|
Numerator 25 · Denominator 28 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 30 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 19.51% |
25.2%
5.7 pts worse
|
Numerator 8 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.3%
8.3 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.8%
3.7 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.4%
0.6 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.5% · Q3 5.5% · Q4 5.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
1.3%
0.7 pts worse
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.3%
3.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.4% · Q3 1.1% · Q4 2.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.1% |
24.9%
15.2 pts worse
|
19.6%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 38.0% · Q3 44.6% · Q4 42.5% · 4Q avg 40.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.8% |
22.8%
6 pts worse
|
16.7%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 28.8% · Q3 27.9% · Q4 26.5% · 4Q avg 28.8% · 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 | 11.6% |
14.8%
3.2 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 13.7% · Q3 5.4% · Q4 13.3% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
13.4%
5 pts better
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.2% · Q3 10.5% · Q4 6.1% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.4% |
13.5%
3.1 pts better
|
19.8%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 14.3% · Q3 11.1% · Q4 10.4% · 4Q avg 10.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.7%
2.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.8% · Q3 4.4% · Q4 0.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
84.3%
15.5 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
11.5%
5 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 16.7% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
2.1%
1.6 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.5% · 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 | 32.0% |
24.5%
7.5 pts worse
|
23.9%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.0% · Observed 28.3% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-08 · Fire 2019-08-08
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-06-14 · Fire 2018-06-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-03-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-05
D · Potential for more than minimal harm
2019-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-18
F · Potential for more than minimal harm
2018-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-07-25
F · Potential for more than minimal harm
2018-06-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-07-25
E · Potential for more than minimal harm
2018-06-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-07-25
D · Potential for more than minimal harm
2018-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-07-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-31
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 2022-05-06
G · Actual harm
2018-06-14
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 2018-06-05
G · Actual harm
2018-06-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-06-05
D · Potential for more than minimal harm
2018-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-19
Penalties and ownership
What sits behind the stars
Ownership
Sims, Mark
5% Or Greater Direct Ownership Interest · Individual
Bazzle, Cheryl
Operational/Managerial Control · Individual
Davis, Brooke
Operational/Managerial Control · Individual
Sims, Mark
Operational/Managerial Control · Individual
Sims, Mark
Corporate Director · Individual
Sims, Mark
Corporate Officer · Individual
Spivey, Dannette
Operational/Managerial Control · Individual
Trintiy Management, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Highlands Health And Rehab
Scottsboro, AL
3-star overall rating with 4-star inspections
#2
Barfield Health Care
Guntersville, AL
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
South Hampton Nursing & Rehabilitation Center
Owens Cross Roads, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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