Cycle 1
Health 2022-02-25 · Fire 2022-02-25
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fairhope, AL
Fairhope Health & Rehab
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
108 South Church Street, Fairhope, AL
(251) 928-2153
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Noland Health
Operator or chain grouping
Approved since
1981-03-12
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
0.47
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.37
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,004
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.88% · Performance 23.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.27% · Performance 9.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.63
Baseline 53.12% · Performance 48.84% · Measure score 3.63 · Achievement 3.63 · Improvement 1.02
Adjusted total nurse staffing
3.71
Baseline 3.85 hours · Performance 4.13 hours · Measure score 3.71 · Achievement 3.71 · Improvement 0.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 9.92% · Lower 95% interval 8.3% |
| Discharge to community | 51.31% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 50.6% · Lower 95% interval 42.89% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 6 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 34 · Adjusted rate 3.87% |
| Healthcare-associated infections requiring hospitalization | 9.46% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 5.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 51 |
| Staff flu vaccination coverage | 66.67% |
42%
24.7 pts better
|
Numerator 52 · Denominator 78 |
| Discharge function score | 31.82% |
56.45%
24.6 pts worse
|
Numerator 7 · Denominator 22 |
| 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 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · 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 | 3.5 |
2.0
1.5 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.0 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.1 · 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 | 94.5% |
94.8%
0.3 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| 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 1.5% · Q2 2.9% · Q3 7.7% · Q4 4.5% · 4Q avg 4.1% · 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 | 1.6% |
5.3%
3.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 4.5% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.6% |
24.9%
10.7 pts worse
|
19.6%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 34.0% · Q3 36.4% · Q4 43.5% · 4Q avg 35.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
22.8%
4.4 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.8% · Q3 15.6% · Q4 21.6% · 4Q avg 18.4% · 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 | 4.1% |
14.8%
10.7 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 8.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
13.4%
6.4 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 2.3% · Q3 2.5% · Q4 11.9% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.3%
0.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.1% |
13.5%
6.4 pts better
|
19.8%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.0% · Q3 7.3% · Q4 10.0% · 4Q avg 7.1% |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
5.7%
3.3 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 8.4% · Q3 10.6% · Q4 9.1% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.5% |
11.5%
4 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 14.5% · 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 4.3% · Q2 1.7% · Q3 1.9% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
80.3%
14.4 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
24.5%
6.8 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 24.2% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-23 · Fire 2019-05-23
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-05-25 · Fire 2018-05-25
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-02-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-04-06
D · Potential for more than minimal harm
2022-02-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-06
F · Potential for more than minimal harm
2019-05-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-07-04
F · Potential for more than minimal harm
2019-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-07-04
F · Potential for more than minimal harm
2019-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-04
E · Potential for more than minimal harm
2019-05-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-07-04
E · Potential for more than minimal harm
2019-05-23
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-07-04
D · Potential for more than minimal harm
2019-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-04
C · Minimal harm
2019-05-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-07-04
F · Potential for more than minimal harm
2018-05-25
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 2018-06-28
E · Potential for more than minimal harm
2018-05-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-06-28
D · Potential for more than minimal harm
2018-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-06-28
C · Minimal harm
2018-05-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-06-28
C · Minimal harm
2018-05-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-06-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-02-25
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 2022-03-31
E · Potential for more than minimal harm
2022-02-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-03-31
E · Potential for more than minimal harm
2022-02-25
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 2022-03-31
E · Potential for more than minimal harm
2022-02-25
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 2022-03-31
D · Potential for more than minimal harm
2022-02-25
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 2022-03-31
D · Potential for more than minimal harm
2022-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-31
D · Potential for more than minimal harm
2019-05-23
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 2019-06-27
D · Potential for more than minimal harm
2018-05-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-06-28
D · Potential for more than minimal harm
2018-05-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-06-28
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
Blackwell, Crystal
Operational/Managerial Control · Individual
Britton, Isaac
Corporate Director · Individual
Champion Partners In Rehab Xvii, LLC
Operational/Managerial Control · Organization
Champion Partners In Rehabilitation LLC
Operational/Managerial Control · Organization
Estep, Barbara
Operational/Managerial Control · Individual
Estep, Barbara
Corporate Director · Individual
Goff, Robert
Corporate Director · Individual
Hall, Matthew
Operational/Managerial Control · Individual
Hall, Randall
Operational/Managerial Control · Individual
Kenwright, Karen
Operational/Managerial Control · Individual
Knight, Carol
Corporate Director · Individual
Mcgill Melton, Cherie
Operational/Managerial Control · Individual
Morrison Management Specialists Inc
Operational/Managerial Control · Organization
Nelson, Debra
Corporate Director · Individual
Noland Health Services, Inc
Operational/Managerial Control · Organization
Noland Pharmacy LLC
Operational/Managerial Control · Organization
Noland Therapies LLC
Operational/Managerial Control · Organization
Quintero, Abel
Operational/Managerial Control · Individual
Renda, Nicholas
Operational/Managerial Control · Individual
Renda, Nicholas
Corporate Director · Individual
Smith, George
Corporate Director · Individual
Smothers, Kathy
Operational/Managerial Control · Individual
Urban, Kelley
Operational/Managerial Control · Individual
Waggoner, James
Corporate Director · Individual
Warren Averett LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Arabella Health And Wellness Of Fairhope
Fairhope, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Eastern Shore Rehabilitation And Health Center
Daphne, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Willowbrooke Ct Skilled Care Ctr Westminster Vlg
Spanish Fort, AL
5-star overall rating with 3-star inspections with 1 recent health deficiencies
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