Cycle 1
Health 2023-07-26 · Fire 2023-07-26
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Northport, AL
Glen Haven Health And Rehabilitation, LLC
1-star overall rating with 1-star inspections with $81,335 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2201 32nd Street, Northport, AL
(205) 339-5700
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
200
Certified beds
Average residents
176
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1977-04-01
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
0.52
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.16
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
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,625
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.51
Baseline 20.16% · Performance 20.27% · Measure score 2.51 · Achievement 2.51 · Improvement 0
Healthcare-associated infections
0
Baseline 8.59% · Performance 8.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.89
Performance 55.95% · Measure score 1.89 · Achievement 1.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.84
Baseline 4.51 hours · Performance 4.45 hours · Measure score 4.84 · Achievement 4.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 12.42% · Lower 95% interval 7.34% |
| Discharge to community | 52.6% |
50.57%
2 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 42.86% · Lower 95% interval 42.53% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 108 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 108 |
| Discharge self-care score | 42.25% |
53.69%
11.4 pts worse
|
Numerator 30 · Denominator 71 |
| Discharge mobility score | 19.72% |
50.94%
31.2 pts worse
|
Numerator 14 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 3.7% |
2.29%
1.4 pts worse
|
Numerator 4 · Denominator 108 · Adjusted rate 3.57% |
| Healthcare-associated infections requiring hospitalization | 8.78% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 11.22% · Lower 95% interval 5.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 189 |
| Staff flu vaccination coverage | 5.36% |
42%
36.6 pts worse
|
Numerator 12 · Denominator 224 |
| Discharge function score | 38.03% |
56.45%
18.4 pts worse
|
Numerator 27 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 54 · Denominator 54 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 15.25% |
25.2%
9.9 pts worse
|
Numerator 9 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.3%
6.9 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.6% · Q3 98.1% · Q4 98.2% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.8%
4.6 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.4% · Q3 1.9% · Q4 3.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.3%
0.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.3%
2.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.8% · Q3 3.4% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
24.9%
2.2 pts better
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 20.0% · Q3 24.2% · Q4 26.4% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
22.8%
5.7 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.3% · Q3 19.1% · Q4 20.0% · 4Q avg 17.1% · 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 | 5.5% |
14.8%
9.3 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 13.1% · Q3 1.7% · Q4 1.6% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
13.4%
8.6 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 9.9% · Q3 2.2% · Q4 3.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.3%
0.4 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.0% · Q3 2.0% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
2.6%
1.4 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.7% · Q3 3.8% · Q4 2.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.3% |
13.5%
6.2 pts better
|
19.8%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 7.6% · Q3 6.3% · Q4 4.3% · 4Q avg 7.3% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.7%
3.4 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 10.7% · Q3 10.2% · Q4 7.1% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.3% |
84.3%
4 pts worse
|
81.7%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.5% · Q2 76.5% · Q3 83.6% · Q4 84.4% · 4Q avg 80.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
11.5%
0.3 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
2.1%
1.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
80.3%
4.9 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
24.5%
5.2 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 19.5% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-24 · Fire 2019-10-24
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-10-11 · Fire 2018-10-11
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-26
F · Potential for more than minimal harm
2023-07-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-26
F · Potential for more than minimal harm
2023-07-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-26
F · Potential for more than minimal harm
2023-07-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-26
D · Potential for more than minimal harm
2023-07-26
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 2023-08-26
E · Potential for more than minimal harm
2019-10-24
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-04
E · Potential for more than minimal harm
2019-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-04
D · Potential for more than minimal harm
2019-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-04
D · Potential for more than minimal harm
2019-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-12-04
D · Potential for more than minimal harm
2019-10-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-12-04
F · Potential for more than minimal harm
2018-10-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2018-11-05
F · Potential for more than minimal harm
2018-10-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2018-10-18
F · Potential for more than minimal harm
2018-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-21
E · Potential for more than minimal harm
2018-10-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-10-22
E · Potential for more than minimal harm
2018-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-11-01
D · Potential for more than minimal harm
2018-10-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-10-18
Inspection history
Recent health citations
K · Immediate jeopardy
2023-07-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-24
K · Immediate jeopardy
2023-07-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-24
F · Potential for more than minimal harm
2023-07-26
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 2023-08-24
E · Potential for more than minimal harm
2023-07-26
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 2023-08-24
E · Potential for more than minimal harm
2023-07-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-26
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 2023-08-24
D · Potential for more than minimal harm
2023-07-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-24
F · Potential for more than minimal harm
2019-10-24
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 2019-11-28
D · Potential for more than minimal harm
2019-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-28
C · Minimal harm
2019-10-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-11-28
F · Potential for more than minimal harm
2018-10-11
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 2018-11-15
Penalties and ownership
What sits behind the stars
$81,335
2023-07-26
Fine
Fine · fine $81,335
Fine
Ownership
Nhs Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Boyd, Casey
Operational/Managerial Control · Individual
Boyd, Casey
Corporate Director · Individual
Duffy, Marcia
Operational/Managerial Control · Individual
Duffy, Marcia
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Martins Ltd
5% Or Greater Security Interest · Organization
Northport Health Services Inc
5% Or Greater Security Interest · Organization
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Shaw, Webster
Operational/Managerial Control · Individual
Shaw, Webster
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Forest Manor Health And Rehab
Northport, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Park Manor Health And Rehabilitation, LLC
Northport, AL
3-star overall rating with 3-star inspections
#3
Aspire Physical Recovery Center Of West Alabama
Northport, AL
4-star overall rating with 4-star inspections
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