Cycle 1
Health 2024-07-03 · Fire 2024-07-03
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Florence, AL
El Reposo Nursing Facility
4-star overall rating with 3-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
260 Milner Chapel Road, Florence, AL
(256) 757-2143
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-03-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.93
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0058
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.71
Baseline 44.29% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
5.58
Baseline 4.34 hours · Performance 4.67 hours · Measure score 5.58 · Achievement 5.58 · Improvement 1.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 40.2% |
42%
1.8 pts worse
|
Numerator 41 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.0
1.1 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.8
1.7 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.3 · Used in QM five-star |
| 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 | 98.3% |
94.8%
3.5 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
3.4%
4 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 8.8% · Q3 7.0% · Q4 6.9% · 4Q avg 7.4% · 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 | 9.5% |
5.3%
4.2 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 14.8% · Q3 5.6% · Q4 9.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 48.6% |
24.9%
23.7 pts worse
|
19.6%
29 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · Q2 51.9% · Q3 50.0% · Q4 45.5% · 4Q avg 48.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.0% |
22.8%
5.2 pts worse
|
16.7%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 28.3% · Q3 28.6% · Q4 26.1% · 4Q avg 28.0% · 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 | 9.6% |
14.8%
5.2 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
13.4%
1 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.1% · Q3 15.0% · Q4 20.0% · 4Q avg 12.4% · 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 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.3% |
2.6%
8.7 pts worse
|
1.7%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 12.3% · Q3 10.5% · Q4 10.3% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
13.5%
4.2 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 13.2% · Q3 19.2% · Q4 14.5% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.7%
1.8 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.5% · Q3 3.5% · Q4 3.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
84.3%
9.5 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-01 · Fire 2019-08-01
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-06-13 · Fire 2018-06-13
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 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
2024-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-31
E · Potential for more than minimal harm
2019-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-20
E · Potential for more than minimal harm
2018-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-22
D · Potential for more than minimal harm
2018-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-07-05
D · Potential for more than minimal harm
2018-06-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-03
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 2024-07-11
D · Potential for more than minimal harm
2018-06-13
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 2018-07-30
D · Potential for more than minimal harm
2018-06-13
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 2018-07-30
C · Minimal harm
2018-06-13
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2018-07-30
Penalties and ownership
What sits behind the stars
Ownership
El Reposo Nursing Facility
5% Or Greater Direct Ownership Interest · Organization
Anerton, Beth
Operational/Managerial Control · Individual
Anerton, Beth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Mitchell-Hollingsworth Nursing & Rehabilitation
Florence, AL
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Florence Nursing And Rehabilitation Ctr, LLC
Florence, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Glenwood Center
Florence, AL
1-star overall rating with 1-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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