Cycle 1
Health 2025-02-03 · Fire 2025-02-03
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Decatur, AL
Decatur Health & Rehab Center
1-star overall rating with 1-star inspections with $25,367 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2326 Morgan Avenue Southwest, Decatur, AL
(256) 340-5765
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Venza Care Management
Operator or chain grouping
Approved since
1977-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 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
0.53
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.11
Baseline 19.66% · Performance 20.91% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Healthcare-associated infections
6.53
Baseline 6.64% · Performance 5.88% · Measure score 6.53 · Achievement 6.53 · Improvement 4.11
Total nurse turnover
0
Baseline 45.00% · Performance 68.10% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.82
Baseline 4.26 hours · Performance 4.16 hours · Measure score 3.82 · Achievement 3.82 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 287 · Observed rate 9.76% · Lower 95% interval 7.72% |
| Discharge to community | 68.75% |
50.57%
18.2 pts better
|
Better than the National Rate · Eligible stays 275 · Observed rate 66.18% · Lower 95% interval 63.91% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 216 · Denominator 216 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 216 |
| Discharge self-care score | 46.53% |
53.69%
7.2 pts worse
|
Numerator 67 · Denominator 144 |
| Discharge mobility score | 39.58% |
50.94%
11.4 pts worse
|
Numerator 57 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 3 · Denominator 216 · Adjusted rate 1.4% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 4.43% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 2.33% |
8.2%
5.9 pts worse
|
Numerator 5 · Denominator 215 |
| Staff flu vaccination coverage | 8.37% |
42%
33.6 pts worse
|
Numerator 18 · Denominator 215 |
| Discharge function score | 36.81% |
56.45%
19.6 pts worse
|
Numerator 53 · Denominator 144 |
| Transfer of health information to provider | 99.07% |
95.95%
3.1 pts better
|
Numerator 106 · Denominator 107 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 64 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 5.66% |
25.2%
19.5 pts worse
|
Numerator 6 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
91.3%
2.3 pts worse
|
93.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 64.6% · Q4 93.2% · 4Q avg 89.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
94.8%
0.3 pts better
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.3% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
1.3%
4.7 pts worse
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.1% · Q3 6.8% · Q4 4.8% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 12.4% |
5.3%
7.1 pts worse
|
5.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 16.4% · Q3 5.1% · Q4 1.5% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
24.9%
1.2 pts better
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.7% · Q3 27.3% · Q4 22.5% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.8% |
22.8%
5 pts worse
|
16.7%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 26.4% · Q3 34.0% · Q4 30.2% · 4Q avg 27.8% · 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 | 39.0% |
14.8%
24.2 pts worse
|
16.3%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.0% · 4Q avg 39.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
13.4%
12.6 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 34.4% · Q3 18.3% · Q4 12.5% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.2% · Q3 1.2% · Q4 0.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 0.0% · Q4 3.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
13.5%
10.1 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 28.6% · Q3 21.7% · Q4 23.1% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.7%
0.1 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 4.0% · Q3 4.7% · Q4 4.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
84.3%
3.1 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 92.4% · Q3 79.6% · Q4 77.3% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
11.5%
8.1 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 18.5% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
2.1%
0.1 pts better
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.0% · Q3 2.4% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.1% |
80.3%
5.8 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
24.5%
1.8 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 23.8% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-15 · Fire 2021-05-15
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-27 · Fire 2020-02-27
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-04
D · Potential for more than minimal harm
2020-02-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-13
Inspection history
Recent health citations
J · Immediate jeopardy
2025-02-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-04
J · Immediate jeopardy
2025-02-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-04
J · Immediate jeopardy
2025-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-02-03
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 2025-03-04
F · Potential for more than minimal harm
2025-02-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-02-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-02-03
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 2024-08-26
D · Potential for more than minimal harm
2025-02-03
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-02-03
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 2025-03-04
D · Potential for more than minimal harm
2025-02-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
J · Immediate jeopardy
2024-05-17
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 2023-09-18
E · Potential for more than minimal harm
2021-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-05-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-06-16
D · Potential for more than minimal harm
2021-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-16
Penalties and ownership
What sits behind the stars
$5,782
2025-02-03
Fine
Fine · fine $5,782
Fine
$5,782
2025-02-03
Fine
Fine · fine $5,782
Fine
$5,782
2025-02-03
Fine
Fine · fine $5,782
Fine
$8,021
2024-05-17
Fine
Fine · fine $8,021
Fine
Ownership
Alabama SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Alabama Opco Manager LLC
Operational/Managerial Control · Organization
Ch Alabama Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Moses Strauss Family 2022 Trust
5% Or Greater Indirect Ownership Interest · Organization
Ms Alabama Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Shirley, Heidi
W-2 Managing Employee · Individual
Ss Alabama Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Strauss, Susan
Operational/Managerial Control · Individual
Strauss, Susan
Corporate Officer · Individual
Susan Strauss Family 2022 Trust
5% Or Greater Indirect Ownership Interest · Organization
Venza Care Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
River City Center
Decatur, AL
1-star overall rating with 1-star inspections with 6 recent health deficiencies
#2
Summerford Health And Rehab, LLC
Falkville, AL
2-star overall rating with 2-star inspections with $25,568 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Falkville Rehabilitation And Healthcare Center
Falkville, AL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $108,343 in total fines with 20 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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