Cycle 1
Health 2023-09-29 · Fire 2023-09-29
4 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Jacksonville, AL
Jacksonville Health And Rehabilitation, LLC
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
410 Wilson Drive Southwest, Jacksonville, AL
(256) 435-7704
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
167
Certified beds
Average residents
149
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1986-10-23
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
0.55
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.10
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.25
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,852
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.37% · Performance 22.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.92% · Performance 8.45% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.47
Performance 45.40% · Measure score 4.47 · Achievement 4.47 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.08
Baseline 3.94 hours · Performance 3.95 hours · Measure score 3.08 · Achievement 3.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 170 · Observed rate 12.94% · Lower 95% interval 8.55% |
| Discharge to community | 47.05% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 41.46% · Lower 95% interval 40.61% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 94.9% |
95.27%
0.4 pts worse
|
Numerator 93 · Denominator 98 |
| Falls with major injury | 3.06% |
0.77%
2.3 pts worse
|
Numerator 3 · Denominator 98 |
| Discharge self-care score | 56.45% |
53.69%
2.8 pts better
|
Numerator 35 · Denominator 62 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 26 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 5.1% |
2.29%
2.8 pts worse
|
Numerator 5 · Denominator 98 · Adjusted rate 5.12% |
| Healthcare-associated infections requiring hospitalization | 8.45% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 11% · Lower 95% interval 5.76% |
| Staff COVID-19 vaccination coverage | 2.67% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 150 |
| Staff flu vaccination coverage | 3.97% |
42%
38 pts worse
|
Numerator 10 · Denominator 252 |
| Discharge function score | 53.23% |
56.45%
3.2 pts worse
|
Numerator 33 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| 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 | 43.48% |
25.2%
18.3 pts better
|
Numerator 20 · Denominator 46 |
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 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.8
1.6 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.3%
8.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.1% |
3.4%
0.3 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.8% · Q3 2.3% · Q4 3.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
1.3%
4.9 pts worse
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.7% · Q3 10.0% · Q4 8.0% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.3%
4 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.9% · Q4 0.9% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.2% |
24.9%
11.3 pts worse
|
19.6%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.8% · Q2 34.2% · Q3 34.5% · Q4 35.0% · 4Q avg 36.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
22.8%
0.1 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 22.9% · Q3 22.7% · Q4 18.1% · 4Q avg 22.9% · 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 | 9.9% |
14.8%
4.9 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 15.1% · Q3 2.1% · Q4 6.0% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
13.4%
4.9 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 7.5% · Q3 5.9% · Q4 2.0% · 4Q avg 8.5% · 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 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.6%
1 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.5% · Q3 3.1% · Q4 1.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.3% |
13.5%
3.2 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 12.1% · Q3 7.2% · Q4 2.8% · 4Q avg 10.3% |
| Percentage of long-stay residents with pressure ulcers | 11.7% |
5.7%
6 pts worse
|
5.1%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 13.3% · Q3 9.2% · Q4 12.6% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
11.5%
7.8 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 3.9% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.1%
0.1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.5% · Q3 2.2% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.3%
19.7 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
24.5%
3.3 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 22.1% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-19 · Fire 2019-09-19
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-09-06 · Fire 2018-09-06
4 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-09-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-13
E · Potential for more than minimal harm
2019-09-19
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-10-30
E · Potential for more than minimal harm
2019-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-09-19
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-10-30
E · Potential for more than minimal harm
2018-09-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-10-15
E · Potential for more than minimal harm
2018-09-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-10-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-09-29
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 2023-10-26
E · Potential for more than minimal harm
2023-09-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-29
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 2023-10-26
C · Minimal harm
2023-09-29
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-26
F · Potential for more than minimal harm
2019-09-19
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 2019-10-24
E · Potential for more than minimal harm
2019-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
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 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-10-24
D · Potential for more than minimal harm
2018-09-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-10-11
D · Potential for more than minimal harm
2018-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-11
C · Minimal harm
2018-09-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-10-11
C · Minimal harm
2018-09-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-10-11
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
Cox, Tammy
Operational/Managerial Control · Individual
Cox, Tammy
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Holding Facilities Group LLC
5% Or Greater Security Interest · Organization
Jacksonville Health Realty LLC
5% Or Greater Security Interest · Organization
Long, Phillip
Corporate Officer · Individual
Odell, David
Operational/Managerial Control · Individual
Patterson, Derek
Operational/Managerial Control · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Piedmont Health Care Center
Piedmont, AL
5-star overall rating with 5-star inspections
#2
Anniston Health And Rehab Services
Anniston, AL
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Anniston
Anniston, AL
3-star overall rating with 2-star inspections with abuse icon flag with $11,057 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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