Cycle 1
Health 2022-08-24 · Fire 2022-08-24
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Columbiana, AL
Columbiana Health And Rehabilitation, LLC
4-star overall rating with 4-star inspections with $8,018 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
22969 Highway 25, Columbiana, AL
(205) 669-1712
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
63
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
2004-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 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
0.49
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.28
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
73%
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
9,785
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.04% · Performance 21.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.98
Baseline 7.57% · Performance 6.65% · Measure score 3.98 · Achievement 3.98 · Improvement 3.09
Total nurse turnover
1.31
Performance 58.33% · Measure score 1.31 · Achievement 1.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.74
Baseline 3.95 hours · Performance 4.14 hours · Measure score 3.74 · Achievement 3.74 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 10.53% · Lower 95% interval 7.11% |
| Discharge to community | 43.67% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 36.21% · Lower 95% interval 32.06% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 40.91% |
53.69%
12.8 pts worse
|
Numerator 9 · Denominator 22 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 10 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 2 · Denominator 34 · Adjusted rate 4.97% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 6.15% |
42%
35.9 pts worse
|
Numerator 8 · Denominator 130 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 11 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · 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 13 · 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 | 2.5 |
2.0
0.5 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.3%
8.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.4%
5.1 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.0% · Q3 11.8% · Q4 10.2% · 4Q avg 8.5% · 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 | 0.6% |
5.3%
4.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.0% |
24.9%
9.1 pts worse
|
19.6%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 31.6% · Q3 34.1% · Q4 30.8% · 4Q avg 34.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.8% |
22.8%
1 pts better
|
16.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.6% · Q3 19.4% · Q4 25.0% · 4Q avg 21.8% · 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 | 6.5% |
14.8%
8.3 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
13.4%
0.9 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.5% · Q3 14.7% · Q4 23.3% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.3%
1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.2% |
13.5%
6.3 pts better
|
19.8%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.1% · Q3 7.9% · Q4 14.5% · 4Q avg 7.2% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.7%
0.2 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 4.4% · Q3 1.6% · Q4 4.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
84.3%
14.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 98.7% |
| 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 6.7% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.1%
2.1 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
80.3%
11.4 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
24.5%
2.5 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 23.3% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-17 · Fire 2019-10-17
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-11-20 · Fire 2018-11-20
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-28
E · Potential for more than minimal harm
2022-08-24
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 2022-09-28
E · Potential for more than minimal harm
2022-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-28
D · Potential for more than minimal harm
2018-11-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-01-02
Inspection history
Recent health citations
G · Actual harm
2024-04-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-16
D · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-23
D · Potential for more than minimal harm
2022-08-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-28
D · Potential for more than minimal harm
2019-10-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-21
Penalties and ownership
What sits behind the stars
$8,018
2024-04-18
Fine
Fine · fine $8,018
Fine
Ownership
Northport Holding Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Cobb, Leigh
Operational/Managerial Control · Individual
Cobb, Leigh
Corporate Director · Individual
Columbiana Health Realty, LLC
5% Or Greater Security Interest · Organization
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Morris, Hilary
Operational/Managerial Control · Individual
Morris, Hilary
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Mortgage Interest · Organization
Smith, Kristin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Shelby Ridge Nursing Home
Alabaster, AL
1-star overall rating with 2-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
The Healthcare Center At Buck Creek
Alabaster, AL
3-star overall rating with 3-star inspections with $16,801 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Riverchase
Birmingham, AL
3-star overall rating with 2-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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