Cycle 1
Health 2022-06-18 · Fire 2022-06-18
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Dothan, AL
Extendicare Health And Rehab
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
950 South St. Andrews Street, Dothan, AL
(334) 793-1177
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
170
Certified beds
Average residents
158
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Noland Health
Operator or chain grouping
Approved since
1978-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 2 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
0.66
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.87
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
5.37
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,317
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.60
Composite VBP score used to determine payment impact.
Payment multiplier
1.0128
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.03
Baseline 24.88% · Performance 20.54% · Measure score 5.03 · Achievement 1.93 · Improvement 5.03
Healthcare-associated infections
7.62
Baseline 5.24% · Performance 5.56% · Measure score 7.62 · Achievement 7.62 · Improvement 0
Total nurse turnover
3.54
Baseline 44.29% · Performance 49.22% · Measure score 3.54 · Achievement 3.54 · Improvement 0
Adjusted total nurse staffing
6.86
Baseline 4.71 hours · Performance 5.03 hours · Measure score 6.86 · Achievement 6.86 · Improvement 2.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.21% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 6.42% · Lower 95% interval 6.48% |
| Discharge to community | 60.41% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 120 · Observed rate 59.17% · Lower 95% interval 52.4% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 184 · Denominator 185 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 185 |
| Discharge self-care score | 42.37% |
53.69%
11.3 pts worse
|
Numerator 50 · Denominator 118 |
| Discharge mobility score | 58.47% |
50.94%
7.5 pts better
|
Numerator 69 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 4.32% |
2.29%
2 pts worse
|
Numerator 8 · Denominator 185 · Adjusted rate 4.85% |
| Healthcare-associated infections requiring hospitalization | 5.56% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 2.17% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 0.77% |
8.2%
7.4 pts worse
|
Numerator 2 · Denominator 261 |
| Staff flu vaccination coverage | 68.17% |
42%
26.2 pts better
|
Numerator 212 · Denominator 311 |
| Discharge function score | 52.54% |
56.45%
3.9 pts worse
|
Numerator 62 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 124 · Denominator 124 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.21% |
25.2%
14 pts worse
|
Numerator 13 · Denominator 116 |
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 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · 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 | 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 | 4.1% |
3.4%
0.7 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.1% · Q3 3.4% · Q4 2.7% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
1.3%
About the same
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 2.1% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
5.3%
5.8 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 16.0% · Q3 11.3% · Q4 10.3% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
24.9%
5.9 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 19.1% · Q3 19.1% · Q4 18.3% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
22.8%
11.7 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 11.3% · Q3 11.5% · Q4 10.8% · 4Q avg 11.1% · 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 | 16.1% |
14.8%
1.3 pts worse
|
16.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 21.0% · Q3 9.7% · Q4 7.9% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
13.4%
4.3 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 24.3% · Q3 15.0% · Q4 11.1% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.3%
0.4 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.6% · Q3 0.0% · Q4 1.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.0% |
2.6%
5.4 pts worse
|
1.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.9% · Q3 8.6% · Q4 5.0% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
13.5%
1.4 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 12.4% · Q3 11.9% · Q4 11.9% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.7%
1.3 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.7% · Q3 3.3% · Q4 5.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
84.3%
13.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 97.3% · Q3 95.4% · Q4 99.2% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.5%
3.7 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.1%
0.7 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.3% · Q4 2.4% · 4Q avg 1.4% · 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 | 27.2% |
24.5%
2.7 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 24.6% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-18 · Fire 2019-07-18
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-08-02 · Fire 2018-08-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-06-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-28
E · Potential for more than minimal harm
2022-06-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-06-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-06-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-01
F · Potential for more than minimal harm
2019-07-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-07-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-29
D · Potential for more than minimal harm
2019-07-18
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-07-26
D · Potential for more than minimal harm
2019-07-18
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-07-18
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2019-08-08
D · Potential for more than minimal harm
2019-07-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-06
C · Minimal harm
2019-07-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-08-08
D · Potential for more than minimal harm
2018-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-08-06
D · Potential for more than minimal harm
2018-08-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-08-06
C · Minimal harm
2018-08-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-06-18
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 2022-07-25
E · Potential for more than minimal harm
2022-06-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-07-25
F · Potential for more than minimal harm
2019-07-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-08-06
F · Potential for more than minimal harm
2019-07-18
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 2019-08-09
D · Potential for more than minimal harm
2019-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-05
D · Potential for more than minimal harm
2019-07-18
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 2019-08-09
F · Potential for more than minimal harm
2018-08-02
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 2018-08-28
D · Potential for more than minimal harm
2018-08-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-08-29
D · Potential for more than minimal harm
2018-08-02
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 2018-09-04
D · Potential for more than minimal harm
2018-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-05
Penalties and ownership
What sits behind the stars
Ownership
Noland Health Services, Inc
5% Or Greater Direct Ownership Interest · Organization
Adamson, Michele
Corporate Director · Individual
Britton, Isaac
Corporate Director · Individual
Estep, Barbara
Operational/Managerial Control · Individual
Estep, Barbara
W-2 Managing Employee · Individual
Ford, Shenika
W-2 Managing Employee · Individual
Goff, Robert
Corporate Director · Individual
Hall, Matthew
W-2 Managing Employee · Individual
Morriss, Jesse
Contracted Managing Employee · Individual
Nelson, Debra
Corporate Director · Individual
Noland Health Services, Inc
Operational/Managerial Control · Organization
Renda, Nicholas
Operational/Managerial Control · Individual
Renda, Nicholas
W-2 Managing Employee · Individual
Smith, George
Corporate Director · Individual
Waggoner, James
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Wesley Place On Honeysuckle
Dothan, AL
2-star overall rating with 2-star inspections with $48,689 in total fines with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Westside Terrace Health & Rehabilitation Center
Dothan, AL
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Graceville Health Center
Graceville, FL
5-star overall rating with 5-star inspections
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