Cycle 1
Health 2023-09-07 · Fire 2023-09-07
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Double Springs, AL
Hendrix Health And Rehabilitation
2-star overall rating with 2-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1000 Highway 33, Double Springs, AL
(205) 489-2136
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-10-01
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
0.59
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.37
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
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,622
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.7
Baseline 18.51% · Performance 19.72% · Measure score 3.7 · Achievement 3.7 · Improvement 0
Healthcare-associated infections
2.66
Baseline 7.31% · Performance 7.04% · Measure score 2.66 · Achievement 2.66 · Improvement 0.66
Total nurse turnover
5.47
Performance 41.30% · Measure score 5.47 · Achievement 5.47 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.38
Baseline 3.35 hours · Performance 3.75 hours · Measure score 2.38 · Achievement 2.38 · Improvement 1.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 6.74% |
| Discharge to community | 55.97% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 54.76% · Lower 95% interval 47.72% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 63 · Denominator 64 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 64 |
| Discharge self-care score | 28.89% |
53.69%
24.8 pts worse
|
Numerator 13 · Denominator 45 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 9 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 1.56% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 64 · Adjusted rate 1.26% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 4.95% |
42%
37 pts worse
|
Numerator 10 · Denominator 202 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 18 · Denominator 45 |
| Transfer of health information to provider | 97.37% |
95.95%
1.4 pts better
|
Numerator 37 · Denominator 38 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 3 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · 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 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.3%
7.6 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.5% · Q4 100.0% · 4Q avg 98.9% |
| 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 | 2.7% |
3.4%
0.7 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 3.4% · Q4 3.5% · 4Q avg 2.7% · 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 | 2.5% |
5.3%
2.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.0% · Q3 2.5% · Q4 1.4% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
24.9%
7.1 pts worse
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 32.6% · Q3 32.9% · Q4 32.5% · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
22.8%
5 pts better
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 18.1% · Q3 20.8% · Q4 13.6% · 4Q avg 17.8% · 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 | 25.7% |
14.8%
10.9 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 26.4% · Q3 15.8% · Q4 20.7% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
13.4%
10.8 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 26.4% · Q3 23.1% · Q4 20.3% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
13.5%
About the same
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.3% · Q3 12.2% · Q4 7.9% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.7%
3.3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 0.0% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
84.3%
15.3 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.5%
2.9 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 8.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.1%
1.4 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
80.3%
18.2 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
24.5%
3.8 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 28.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-29 · Fire 2019-10-29
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-09-12 · Fire 2018-09-12
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-07
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-09-07
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-10-18
E · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-18
D · Potential for more than minimal harm
2023-09-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-18
F · Potential for more than minimal harm
2019-10-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-21
D · Potential for more than minimal harm
2019-10-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-21
F · Potential for more than minimal harm
2018-09-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-10-23
E · Potential for more than minimal harm
2018-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-10-23
E · Potential for more than minimal harm
2018-09-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-10-23
D · Potential for more than minimal harm
2018-09-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-10-23
D · Potential for more than minimal harm
2018-09-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-10-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-09-07
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 2023-10-12
F · Potential for more than minimal harm
2023-09-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
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 2023-10-12
F · Potential for more than minimal harm
2019-10-29
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 2019-11-21
D · Potential for more than minimal harm
2019-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-21
E · Potential for more than minimal harm
2018-09-12
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 2018-10-17
D · Potential for more than minimal harm
2018-09-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-10-17
Penalties and ownership
What sits behind the stars
Ownership
The Barry Lynn Hendrix Gst Trust (2009)
5% Or Greater Direct Ownership Interest · Organization
The Dale Frank Hendrix Jr Gst Trust (2009)
5% Or Greater Direct Ownership Interest · Organization
The Jeffrey Byron Hendrix Gst Trust (2009)
5% Or Greater Direct Ownership Interest · Organization
Bell, Shannon
Operational/Managerial Control · Individual
Bell, Shannon
Contracted Managing Employee · Individual
Hendrix, Barry
Operational/Managerial Control · Individual
Hendrix, Barry
Corporate Director · Individual
Hendrix, Dale
Operational/Managerial Control · Individual
Hendrix, Dale
Corporate Director · Individual
Hendrix, Dale
Corporate Officer · Individual
Hendrix, Jeffrey
Operational/Managerial Control · Individual
Hendrix, Jeffrey
Corporate Director · Individual
Hendrix, Jeffrey
Corporate Officer · Individual
Nhs Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Haleyville Health Care Center
Haleyville, AL
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Walker Rehabilitation Center, Inc
Carbon Hill, AL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $235,127 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Moulton
Moulton, AL
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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