Cycle 1
Health 2022-01-14 · Fire 2022-01-14
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Huntsville, AL
Huntsville Health & Rehabilitation, LLC
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4010 Chris Drive, Huntsville, AL
(256) 883-8656
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1999-11-18
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
0.72
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,748
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9958
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.71% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
7.50
Baseline 5.45% · Performance 5.59% · Measure score 7.50 · Achievement 7.50 · Improvement 0
Total nurse turnover
2.87
Performance 51.97% · Measure score 2.87 · Achievement 2.87 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.78
Baseline 4.06 hours · Performance 5.01 hours · Measure score 6.78 · Achievement 6.78 · Improvement 5
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 11.43% · Lower 95% interval 7.42% |
| Discharge to community | 41.86% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 33.33% · Lower 95% interval 29.22% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 39.29% |
53.69%
14.4 pts worse
|
Numerator 11 · Denominator 28 |
| Discharge mobility score | 64.29% |
50.94%
13.4 pts better
|
Numerator 18 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.6% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 0% · Lower 95% interval 2.34% |
| Staff COVID-19 vaccination coverage | 3.26% |
8.2%
4.9 pts worse
|
Numerator 3 · Denominator 92 |
| Staff flu vaccination coverage | 26.92% |
42%
15.1 pts worse
|
Numerator 42 · Denominator 156 |
| Discharge function score | 60.71% |
56.45%
4.3 pts better
|
Numerator 17 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
91.3%
2.9 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 88.6% · Q3 87.8% · Q4 86.7% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.6% |
94.8%
14.2 pts worse
|
95.5%
14.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.4%
0.1 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 4.9% · Q4 2.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
1.3%
0.4 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 1.4% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.3%
1.6 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 4.1% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
24.9%
10.6 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 14.3% · Q3 14.7% · Q4 13.7% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
22.8%
3.7 pts better
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 17.7% · Q3 20.0% · Q4 22.6% · 4Q avg 19.1% · 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 | 16.7% |
14.8%
1.9 pts worse
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 19.5% · Q3 12.6% · Q4 14.1% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
13.4%
3.7 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.0% · Q3 10.3% · Q4 11.8% · 4Q avg 9.7% · 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 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.6%
1.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.2% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
13.5%
4.6 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 18.8% · Q3 20.5% · Q4 11.1% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.7%
2.2 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.0% · Q3 14.1% · Q4 7.6% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
84.3%
0.5 pts worse
|
81.7%
2.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 89.4% · Q3 86.7% · Q4 81.3% · 4Q avg 83.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
11.5%
0.6 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 11.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.1%
0.8 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.9% |
80.3%
6.4 pts worse
|
79.7%
5.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
24.5%
7.9 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 17.0% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-24 · Fire 2019-10-24
1 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-09-12 · Fire 2018-09-12
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-01-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-23
E · Potential for more than minimal harm
2022-01-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-01-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-01-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-01-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-02-23
F · 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 2019-11-28
F · Potential for more than minimal harm
2019-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-28
E · Potential for more than minimal harm
2019-10-24
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 2019-11-28
D · Potential for more than minimal harm
2019-10-24
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2019-11-28
F · Potential for more than minimal harm
2018-09-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-10-25
D · Potential for more than minimal harm
2018-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-01-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-02-18
D · Potential for more than minimal harm
2022-01-14
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 2022-02-18
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
F · Potential for more than minimal harm
2018-09-12
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-11-23
F · 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
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 2018-10-17
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
Capital Funding LLC
5% Or Greater Security Interest · Organization
Capital Funding LLC
5% Or Greater Mortgage Interest · Organization
Chandler, Anita
Operational/Managerial Control · Individual
Cox, Tammy
Operational/Managerial Control · Individual
Cox, Tammy
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Huntsville Health Realty, LLC
5% Or Greater Security Interest · Organization
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Ward, Sonny
Operational/Managerial Control · Individual
Ward, Sonny
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Willowbrooke Ct Skilled Care Ctr At Magnolia Trace
Huntsville, AL
5-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Rocket City Rehabilitation And Healthcare Center
Huntsville, AL
1-star overall rating with 1-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Big Springs
Huntsville, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
Jump out