Cycle 1
Health 2024-01-04 · Fire 2024-01-04
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Montgomery, AL
John Knox Manor Inc I I
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4401 Narrow Lane Road, Montgomery, AL
(334) 281-6336
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-05-10
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
0.57
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
82%
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
7,246
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
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
0
Performance 73.86% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.06
Baseline 5.47 hours · Performance 4.80 hours · Measure score 6.06 · Achievement 6.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 46 · Observed rate 8.7% · Lower 95% interval 5.9% |
| Discharge to community | 31.5% |
50.57%
19.1 pts worse
|
Worse than the National Rate · Eligible stays 38 · Observed rate 15.79% · Lower 95% interval 19.54% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 2.33% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.54% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 113 |
| Staff flu vaccination coverage | 28.66% |
42%
13.3 pts worse
|
Numerator 47 · Denominator 164 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 2.9 |
2.0
0.9 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.0 · Expected 1.3 · 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 2.1 · Expected 1.3 · 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 | 5.0% |
3.4%
1.6 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.6% · Q3 4.8% · Q4 4.9% · 4Q avg 5.0% · 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 | 4.3% |
5.3%
1 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 0.0% · Q4 7.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
24.9%
18.8 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.8% · Q3 2.5% · Q4 7.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
22.8%
1.2 pts better
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 20.8% · Q3 14.9% · Q4 22.9% · 4Q avg 21.6% · 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 | 19.7% |
14.8%
4.9 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.9% |
13.4%
8.5 pts worse
|
14.9%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 29.4% · Q3 21.2% · Q4 11.4% · 4Q avg 21.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 1.4% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 1.6% · Q4 6.6% · 4Q avg 3.8% · 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 17.7% · Q2 15.0% · Q3 13.6% · Q4 8.5% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.7%
0.3 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.6% · Q3 9.3% · Q4 4.9% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
84.3%
13.6 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 97.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-10 · Fire 2019-10-10
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-08 · Fire 2018-11-08
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-04
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-01-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-15
D · Potential for more than minimal harm
2019-10-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-19
E · Potential for more than minimal harm
2018-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-12-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-01-04
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 2024-02-08
D · Potential for more than minimal harm
2024-01-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-08
D · Potential for more than minimal harm
2024-01-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-08
D · Potential for more than minimal harm
2018-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-13
Penalties and ownership
What sits behind the stars
Ownership
Brummal, Edward
Corporate Director · Individual
Howell, Terri
Operational/Managerial Control · Individual
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