Cycle 1
Health 2022-02-04 · Fire 2022-02-04
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Abbeville, AL
Henry County Health And Rehabilitation Facility
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
212 Dothan Road, Abbeville, AL
(334) 585-2241
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
81
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-12-12
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
0.70
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
5.09
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.43
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
0.79
CMS adjusted RN staffing hours
Adjusted total hours
5.78
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0100
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
5.10
Baseline 6.14% · Performance 6.31% · Measure score 5.10 · Achievement 5.10 · Improvement 0
Total nurse turnover
1.42
Baseline 39.56% · Performance 57.89% · Measure score 1.42 · Achievement 1.42 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.70 hours · Performance 6.11 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 6.9% · Lower 95% interval 6.18% |
| Discharge to community | 61.6% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 31 · Observed rate 64.52% · Lower 95% interval 50.64% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.87% |
95.27%
0.4 pts worse
|
Numerator 37 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 34.48% |
53.69%
19.2 pts worse
|
Numerator 10 · Denominator 29 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 10 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 3 · Denominator 39 · Adjusted rate 6.34% |
| Healthcare-associated infections requiring hospitalization | 6.31% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 116 |
| Staff flu vaccination coverage | 49.59% |
42%
7.6 pts better
|
Numerator 60 · Denominator 121 |
| Discharge function score | 44.83% |
56.45%
11.6 pts worse
|
Numerator 13 · Denominator 29 |
| 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 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.0
0.8 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 1.7 · Expected 1.2 · 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 0.9 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.3%
8.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.8%
3.9 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.4%
0.5 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.9% · Q3 2.6% · Q4 4.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
1.3%
3.3 pts worse
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 6.8% · Q4 6.5% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.3%
2.7 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.7% · Q3 6.8% · Q4 11.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
24.9%
0.4 pts better
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 27.9% · Q3 27.4% · Q4 23.1% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.7% |
22.8%
10.9 pts worse
|
16.7%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 29.5% · Q3 38.5% · Q4 38.5% · 4Q avg 33.7% · 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 | 4.4% |
14.8%
10.4 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.4% · Q3 3.2% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
13.4%
2.4 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 16.7% · Q3 11.1% · Q4 10.3% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.3%
0.2 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 1.0% · Q4 1.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 2.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
13.5%
1.9 pts worse
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 21.8% · Q3 12.5% · Q4 11.8% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.7%
1.8 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.7% · Q3 6.5% · Q4 9.8% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
84.3%
9.2 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 88.9% · Q3 100.0% · Q4 89.7% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
11.5%
2.8 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 8.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
2.1%
1.7 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 5.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.5% |
80.3%
9.2 pts better
|
79.7%
9.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
24.5%
3.7 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 19.4% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-16 · Fire 2019-05-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2018-06-14 · Fire 2018-06-14
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-02-04
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 2022-03-16
E · Potential for more than minimal harm
2022-02-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-16
D · Potential for more than minimal harm
2022-02-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-16
F · Potential for more than minimal harm
2019-05-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-06-28
E · Potential for more than minimal harm
2018-06-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-07-23
D · Potential for more than minimal harm
2018-06-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-07-23
D · Potential for more than minimal harm
2018-06-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-07-23
C · Minimal harm
2018-06-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-07-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-02-04
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-02-04
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 2022-03-11
D · Potential for more than minimal harm
2022-02-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-11
F · Potential for more than minimal harm
2019-05-16
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 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-20
F · Potential for more than minimal harm
2018-06-14
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 2018-07-19
D · Potential for more than minimal harm
2018-06-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-07-19
D · Potential for more than minimal harm
2018-06-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-07-19
D · Potential for more than minimal harm
2018-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-19
C · Minimal harm
2018-06-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-07-19
Penalties and ownership
What sits behind the stars
Ownership
Henry County Health Care Authority
5% Or Greater Direct Ownership Interest · Organization
Houston, Charlie
Corporate Director · Individual
Money, Marquita
Operational/Managerial Control · Individual
Money, Marquita
W-2 Managing Employee · Individual
Smith, Betty
Corporate Director · Individual
Tye, Judy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Fort Gaines Health And Rehab
Fort Gaines, GA
2-star overall rating with 2-star inspections with 12 recent health deficiencies
#2
Early Memorial Nursing Facility
Blakely, GA
1-star overall rating with 1-star inspections with $177,463 in total fines with 9 recent health deficiencies
#3
Ozark Health And Rehabilitation, LLC
Ozark, AL
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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