3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lafayette, AL
3-star overall rating with 3-star inspections with $4,558 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
805 Hospital Street Southwest, Lafayette, AL
(334) 864-8854
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
69
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prime Health Care Enterprises
Operator or chain grouping
Approved since
1978-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 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
RN hours / resident day
0.46
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
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
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
490
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.98
Composite VBP score used to determine payment impact.
Payment multiplier
1.0218
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
9.24
Baseline 34.09% · Performance 25.93% · Measure score 9.24 · Achievement 9.24 · Improvement 8.34
Adjusted total nurse staffing
4.56
Baseline 4.56 hours · Performance 4.37 hours · Measure score 4.56 · Achievement 4.56 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 5.99% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 9.38% |
42%
32.6 pts worse
|
Numerator 6 · Denominator 64 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
| 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 | 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 | 72.5% |
91.3%
18.8 pts worse
|
93.4%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.5% · Q2 85.5% · Q3 73.8% · Q4 62.3% · 4Q avg 72.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
94.8%
0.1 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.4%
1.3 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.8% · Q3 1.6% · Q4 1.6% · 4Q avg 2.1% · 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 | 7.5% |
5.3%
2.2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 4.7% · Q3 7.5% · Q4 3.8% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
24.9%
8.2 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.7% · Q3 17.0% · Q4 16.4% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
22.8%
5.1 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 17.1% · Q3 16.3% · Q4 20.9% · 4Q avg 17.7% · 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 | 6.8% |
14.8%
8 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
13.4%
3.5 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.5% · Q3 11.1% · Q4 11.1% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.3%
0.8 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.5% · Q3 1.2% · Q4 1.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.6% · Q4 5.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.9% |
13.5%
6.6 pts better
|
19.8%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.8% · Q3 6.6% · Q4 3.3% · 4Q avg 6.9% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.7%
2.8 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 12.0% · Q3 7.9% · Q4 7.7% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 37.5% |
84.3%
46.8 pts worse
|
81.7%
44.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 37.5% |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-02-25
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-02-25
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2020-02-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-25
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-02-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-02-06
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2019-02-06
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-03-09
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-03-09
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-03-09
Inspection history
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-02-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-02-26
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 2020-02-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-01-23
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-01-23
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 2019-01-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-03-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-03-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-03-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-03-08
Health
Provide and implement an infection prevention and control program.
Corrected 2018-03-08
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2018-03-08
Health
Post nurse staffing information every day.
Corrected 2018-03-08
Penalties and ownership
Fine · fine $4,558
Fine
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
Nearby options
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