Cycle 1
Health 2022-08-24 · Fire 2022-08-24
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Ashville, AL
Health Care Inc
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
38286 Us Highway 231, Ashville, AL
(205) 594-5148
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-08-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.33
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.03
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,088
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0152
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.44
Baseline 100.00% · Performance 55.36% · Measure score 5.44 · Achievement 2.04 · Improvement 5.44
Adjusted total nurse staffing
6.56
Baseline 1.15 hours · Performance 4.42 hours · Measure score 6.56 · Achievement 4.71 · Improvement 6.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 2.99% |
8.2%
5.2 pts worse
|
Numerator 2 · Denominator 67 |
| Staff flu vaccination coverage | 55.22% |
42%
13.2 pts better
|
Numerator 37 · Denominator 67 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
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 | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.9% |
91.3%
17.4 pts worse
|
93.4%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 72.5% · Q3 71.2% · Q4 73.5% · 4Q avg 73.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.8%
2.5 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.4%
2.1 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.9% · Q3 5.8% · Q4 8.2% · 4Q avg 5.5% · 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 | 6.9% |
5.3%
1.6 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.8% · Q3 4.7% · Q4 7.0% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 56.1% |
24.9%
31.2 pts worse
|
19.6%
36.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.8% · Q2 59.1% · Q3 55.8% · Q4 53.5% · 4Q avg 56.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 60.7% |
22.8%
37.9 pts worse
|
16.7%
44 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 60.7% · 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 | 1.6% |
14.8%
13.2 pts better
|
16.3%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
13.4%
8 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 7.1% · Q4 9.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.3%
0.9 pts better
|
1.0%
0.6 pts better
|
Long 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 long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 6.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.6% |
13.5%
9.9 pts better
|
19.8%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 5.0% · Q4 3.7% · 4Q avg 3.6% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.7%
1.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 4.7% · Q4 4.7% · 4Q avg 3.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-12 · Fire 2021-08-12
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (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 2022-09-16
E · Potential for more than minimal harm
2022-08-24
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 2022-09-19
D · Potential for more than minimal harm
2022-08-24
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 2022-09-19
D · Potential for more than minimal harm
2022-08-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-16
D · Potential for more than minimal harm
2019-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-08-24
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 2022-09-23
D · Potential for more than minimal harm
2022-08-24
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 2022-09-23
D · Potential for more than minimal harm
2022-08-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-23
F · Potential for more than minimal harm
2019-08-08
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 2019-08-30
D · Potential for more than minimal harm
2019-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-30
Penalties and ownership
What sits behind the stars
Ownership
Penland, Pam
5% Or Greater Direct Ownership Interest · Individual
Penland, Pam
Corporate Director · Individual
Penland, Pam
Corporate Officer · Individual
Penland, Pam
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with 4 fire-safety deficiencies in the latest cycle
#2
Diversicare Of Oneonta
Oneonta, AL
2-star overall rating with 2-star inspections with $9,318 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Altoona Health & Rehab
Altoona, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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