Cycle 1
Health 2022-08-24 · Fire 2022-08-24
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Florala, AL
Florala Health And Rehabilitation LLC
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
23621 Goldenrod Avenue, Florala, AL
(334) 858-8585
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
2003-08-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 3 overall / 3 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
0.63
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.87
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
3.39
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.26
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
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,589
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9967
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.4
Baseline 20.89% · Performance 18.00% · Measure score 7.4 · Achievement 7.4 · Improvement 6.98
Healthcare-associated infections
3.07
Baseline 7.59% · Performance 6.92% · Measure score 3.07 · Achievement 3.07 · Improvement 2.10
Total nurse turnover
3.03
Performance 51.28% · Measure score 3.03 · Achievement 3.03 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.95
Baseline 4.55 hours · Performance 4.20 hours · Measure score 3.95 · Achievement 3.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 101 · Observed rate 9.9% · Lower 95% interval 7.37% |
| Discharge to community | 51.88% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 44.58% · Lower 95% interval 40.89% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 46.34% |
53.69%
7.3 pts worse
|
Numerator 19 · Denominator 41 |
| Discharge mobility score | 39.02% |
50.94%
11.9 pts worse
|
Numerator 16 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 5.19% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 3.45% |
8.2%
4.7 pts worse
|
Numerator 3 · Denominator 87 |
| Staff flu vaccination coverage | 14.71% |
42%
27.3 pts worse
|
Numerator 15 · Denominator 102 |
| Discharge function score | 53.66% |
56.45%
2.8 pts worse
|
Numerator 22 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · 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 | 40.63% |
25.2%
15.4 pts better
|
Numerator 13 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.0
1.1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
1.8
1.7 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.0 · Expected 1.4 · 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 | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 4.3% · Q4 1.5% · 4Q avg 2.2% · 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 | 7.1% |
5.3%
1.8 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.4% · Q3 7.5% · Q4 3.2% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
24.9%
3.3 pts better
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 20.0% · Q3 20.6% · Q4 25.4% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.5% |
22.8%
15.7 pts worse
|
16.7%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.8% · Q2 42.9% · Q3 41.1% · Q4 32.7% · 4Q avg 38.5% · 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 | 6.5% |
14.8%
8.3 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.7% · Q3 3.5% · Q4 7.2% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
13.4%
4.7 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 7.1% · Q3 2.0% · Q4 10.4% · 4Q avg 8.7% · 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 | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 1.4% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.3% |
13.5%
2.2 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 12.8% · Q3 7.1% · Q4 13.4% · 4Q avg 11.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.7%
0.7 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.8% · Q3 7.9% · Q4 9.2% · 4Q avg 6.4% · 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 | 15.9% |
11.5%
4.4 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 16.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
2.1%
0.9 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 4.8% · Q4 4.2% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
80.3%
13.3 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
24.5%
7.8 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 14.6% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-13 · Fire 2020-02-13
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-12-13 · Fire 2018-12-13
2 health deficiencies
Top issue: Infection Control (1 deficiency)
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
2022-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-28
E · Potential for more than minimal harm
2022-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-31
D · Potential for more than minimal harm
2020-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-24
D · Potential for more than minimal harm
2020-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-24
D · Potential for more than minimal harm
2020-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-24
E · Potential for more than minimal harm
2018-12-13
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 2019-01-22
E · Potential for more than minimal harm
2018-12-13
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 2019-01-22
D · Potential for more than minimal harm
2018-12-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-12
D · Potential for more than minimal harm
2018-12-13
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 2019-01-17
D · Potential for more than minimal harm
2018-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-17
Penalties and ownership
What sits behind the stars
Ownership
Northport Holding Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Braswell, Crystal
Operational/Managerial Control · Individual
Braswell, Crystal
W-2 Managing Employee · Individual
Capital Funding LLC
5% Or Greater Security Interest · Organization
Capital Funding LLC
5% Or Greater Mortgage Interest · Organization
Estes, James
Corporate Officer · Individual
Florala Health Realty LLC
5% Or Greater Security Interest · Organization
Holding Facilities Group LLC
5% Or Greater Security Interest · Organization
Howell, Rhonda
Operational/Managerial Control · Individual
Howell, Rhonda
Corporate Director · Individual
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Richburg, Julie
Operational/Managerial Control · Individual
Richburg, Julie
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
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
Crestview Rehabilitation Center, LLC
Crestview, FL
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Andalusia Manor
Andalusia, AL
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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