Cycle 1
Health 2022-05-17 · Fire 2022-05-17
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Elba, AL
Elba Nursing And Rehabilitation Center, LLC
1-star overall rating with 2-star inspections with 4 recent health deficiencies
987 Drayton Street, Elba, AL
(334) 897-2257
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Norbert Bennett & Donald Denz
Operator or chain grouping
Approved since
1967-05-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 2 health / 3 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
0.84
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.58
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
1.04
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,442
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.38
Baseline 21.88% · Performance 20.48% · Measure score 2.38 · Achievement 2.05 · Improvement 2.38
Healthcare-associated infections
0.52
Baseline 9.17% · Performance 8.74% · Measure score 0.52 · Achievement 0 · Improvement 0.52
Total nurse turnover
2.28
Baseline 50.00% · Performance 54.35% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Adjusted total nurse staffing
2.97
Baseline 3.36 hours · Performance 3.92 hours · Measure score 2.97 · Achievement 2.97 · Improvement 1.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 11.54% · Lower 95% interval 7.95% |
| Discharge to community | 45.56% |
50.57%
5 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 37.7% · Lower 95% interval 34.98% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 61.54% |
95.27%
33.7 pts worse
|
Numerator 16 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · 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 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.74% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 5.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 139 |
| Staff flu vaccination coverage | 11.17% |
42%
30.8 pts worse
|
Numerator 21 · Denominator 188 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · 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 | 2.7 |
2.0
0.7 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.0 · Expected 1.4 · 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 2.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.3%
8.1 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.8%
3 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.4%
2.6 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.9% · Q3 6.8% · Q4 6.9% · 4Q avg 6.0% · 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 | 5.4% |
5.3%
0.1 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.4% · Q3 7.7% · Q4 5.6% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.6% |
24.9%
15.7 pts worse
|
19.6%
21 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.4% · Q2 42.1% · Q3 40.5% · Q4 36.1% · 4Q avg 40.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
22.8%
3.7 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 33.3% · Q3 27.9% · Q4 18.5% · 4Q avg 26.5% · 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 | 25.0% |
14.8%
10.2 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 20.6% · Q3 32.5% · Q4 29.7% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
13.4%
8.4 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 21.1% · Q3 28.2% · Q4 28.4% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.3%
1.1 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 10.2% |
13.5%
3.3 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.9% · Q3 13.4% · Q4 9.6% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.7%
1.1 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.8% · Q3 5.7% · Q4 9.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.4% |
84.3%
4.9 pts worse
|
81.7%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.4% · Q2 66.7% · Q3 97.1% · Q4 100.0% · 4Q avg 79.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
11.5%
3.5 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 19.0% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
2.1%
2.7 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
80.3%
6.4 pts worse
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
24.5%
7.9 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 19.0% · Expected 27.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-08 · Fire 2021-07-08
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-03-20 · Fire 2019-03-20
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-07-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-08-19
D · Potential for more than minimal harm
2021-07-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-19
D · Potential for more than minimal harm
2021-07-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-08-19
D · Potential for more than minimal harm
2021-07-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-19
F · Potential for more than minimal harm
2019-03-20
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2019-04-19
E · Potential for more than minimal harm
2019-03-20
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-03-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-04-19
D · Potential for more than minimal harm
2019-03-20
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 2019-04-19
D · Potential for more than minimal harm
2019-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-03-02
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 2023-03-31
F · Potential for more than minimal harm
2022-05-17
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-17
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 2022-06-20
D · Potential for more than minimal harm
2021-07-08
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 2021-08-10
D · Potential for more than minimal harm
2021-07-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-07-08
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 2021-08-10
D · Potential for more than minimal harm
2021-07-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-08-10
D · Potential for more than minimal harm
2019-03-20
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 2019-04-19
D · Potential for more than minimal harm
2019-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-19
C · Minimal harm
2019-03-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-04-19
Penalties and ownership
What sits behind the stars
Ownership
Bp Ii LLC
5% Or Greater Direct Ownership Interest · Organization
D&N, LLC
5% Or Greater Direct Ownership Interest · Organization
Denz, Donald
5% Or Greater Indirect Ownership Interest · Individual
Bennett, Norbert
5% Or Greater Indirect Ownership Interest · Individual
Norbert A Bennett Irrv Tr Fbo Children
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Grandchildren
5% Or Greater Indirect Ownership Interest · Organization
Hall, Nikki
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Opp Health And Rehabilitation, LLC
Opp, AL
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Enterprise Health & Rehabilitation Center
Enterprise, AL
1-star overall rating with 1-star inspections with abuse icon flag with $68,070 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Luverne Health And Rehabilitation, LLC
Luverne, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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