Cycle 1
Health 2024-11-20 · Fire 2024-11-20
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cordova, AL
Cordova Health And Rehabilitation, LLC
1-star overall rating with 1-star inspections with abuse icon flag with $76,242 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
70 Highland Street West, Cordova, AL
(205) 483-9282
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1971-04-01
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
0.58
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.07
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
5.40
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.80
Baseline 7.02% · Performance 7.60% · Measure score 0.80 · Achievement 0.80 · Improvement 0
Total nurse turnover
3.56
Performance 49.12% · Measure score 3.56 · Achievement 3.56 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.41
Baseline 3.90 hours · Performance 4.62 hours · Measure score 5.41 · Achievement 5.41 · Improvement 3.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 10.94% · Lower 95% interval 7.8% |
| Discharge to community | 47.72% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 43.4% · Lower 95% interval 38.16% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 70.37% |
95.27%
24.9 pts worse
|
Numerator 19 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 7.69% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 12.77% |
8.2%
4.6 pts better
|
Numerator 12 · Denominator 94 |
| Staff flu vaccination coverage | 7.69% |
42%
34.3 pts worse
|
Numerator 8 · Denominator 104 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.3%
8.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.8%
4.3 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.4%
2.4 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.0% · 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 | 14.2% |
5.3%
8.9 pts worse
|
5.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 23.2% · Q3 16.5% · Q4 9.3% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.1% |
24.9%
6.2 pts worse
|
19.6%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 31.6% · Q3 26.1% · Q4 26.4% · 4Q avg 31.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
22.8%
0.7 pts better
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 21.7% · Q3 20.6% · Q4 19.4% · 4Q avg 22.1% · 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 | 6.2% |
14.8%
8.6 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.4% · Q3 12.9% · Q4 6.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
13.4%
8.4 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.3% · Q3 8.0% · Q4 4.7% · 4Q avg 5.0% · 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 | 3.9% |
2.6%
1.3 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 5.1% · Q3 5.2% · Q4 4.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.6% |
13.5%
7.9 pts better
|
19.8%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 6.6% · Q3 8.3% · Q4 5.8% · 4Q avg 5.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.7%
0.7 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.1% · Q3 5.4% · Q4 2.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
84.3%
15.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
11.5%
6.9 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 5.0% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
2.1%
2.3 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.7% · Q3 0.0% · Q4 3.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.3%
19.7 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
24.5%
4.7 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 30.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-03 · Fire 2019-10-03
1 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-09-06 · Fire 2018-09-06
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-25
E · Potential for more than minimal harm
2024-11-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-25
D · Potential for more than minimal harm
2024-11-20
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-12-25
D · Potential for more than minimal harm
2024-11-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-12-25
D · Potential for more than minimal harm
2024-11-20
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 2024-12-25
D · Potential for more than minimal harm
2024-11-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-25
F · Potential for more than minimal harm
2019-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-13
D · Potential for more than minimal harm
2019-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-11-13
D · Potential for more than minimal harm
2019-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-13
D · Potential for more than minimal harm
2019-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-13
D · Potential for more than minimal harm
2019-10-03
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 2019-11-13
D · Potential for more than minimal harm
2019-10-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-11-14
D · Potential for more than minimal harm
2019-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-13
E · Potential for more than minimal harm
2018-09-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-17
E · Potential for more than minimal harm
2018-09-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-10-17
E · Potential for more than minimal harm
2018-09-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-06
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 2018-10-17
D · Potential for more than minimal harm
2018-09-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-10-17
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-20
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 2024-12-21
J · Immediate jeopardy
2024-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-21
F · Potential for more than minimal harm
2024-11-20
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 2024-12-21
F · Potential for more than minimal harm
2024-11-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-21
E · Potential for more than minimal harm
2024-11-20
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 2024-12-21
D · Potential for more than minimal harm
2024-11-20
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 2024-12-21
D · Potential for more than minimal harm
2024-11-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-21
C · Minimal harm
2024-11-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-21
D · Potential for more than minimal harm
2019-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-06
F · Potential for more than minimal harm
2018-09-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-10-11
F · Potential for more than minimal harm
2018-09-06
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 2018-10-11
D · Potential for more than minimal harm
2018-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-11
Penalties and ownership
What sits behind the stars
$76,242
2024-11-20
Fine
Fine · fine $76,242
Fine
$0
2024-11-20
Payment Denial
Payment Denial · denial start 2024-12-21 · 4 days
4 day denial
Ownership
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
South-Care Medical Facilities, Inc.
5% Or Greater Direct Ownership Interest · Organization
Cox, Tammy
Operational/Managerial Control · Individual
Cox, Tammy
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Raines, Stephen
Operational/Managerial Control · 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
South-Care Medical Facilities, Inc.
5% Or Greater Security Interest · Organization
Ward, Sonny
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Shadescrest Health Care Center
Jasper, AL
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ridgeview Health Services, Inc
Jasper, AL
2-star overall rating with 2-star inspections with $13,520 in total fines with 5 recent health deficiencies
#3
Ridgewood Health Services, Inc.
Jasper, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out