Cycle 1
Health 2020-03-12 · Fire 2020-03-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mobile, AL
Little Sisters Of The Poor Sacred Heart Residence
5-star overall rating with 5-star inspections with 1 recent health deficiencies
1655 Mcgill Avenue, Mobile, AL
(251) 476-6335
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-07-01
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
0.86
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.98
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.27
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
6.51
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,865
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.29
Composite VBP score used to determine payment impact.
Payment multiplier
1.0008
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.33% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.29
Performance 6.55% · Measure score 4.29 · Achievement 4.29 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.35
Baseline 54.55% · Performance 41.82% · Measure score 5.35 · Achievement 5.35 · Improvement 3.79
Adjusted total nurse staffing
9.28
Baseline 6.13 hours · Performance 5.72 hours · Measure score 9.28 · Achievement 9.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 4.76% · Lower 95% interval 6.11% |
| 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 | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 162 |
| Staff flu vaccination coverage | 68.1% |
42%
26.1 pts better
|
Numerator 111 · Denominator 163 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| 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 7 · 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 | 3.4 |
2.0
1.4 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.4 · 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 | 6.8% |
3.4%
3.4 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 8.8% · Q4 8.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
1.3%
2.4 pts worse
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 2.9% · Q4 0.0% · 4Q avg 3.7% |
| 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 2.7% · Q2 2.8% · Q3 0.0% · Q4 11.1% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
24.9%
1.6 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 24.3% · Q3 29.4% · Q4 27.0% · 4Q avg 26.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
22.8%
9.8 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 9.1% · Q3 12.5% · Q4 8.0% · 4Q avg 13.0% · 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 | 13.8% |
14.8%
1 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 4.5% · Q4 19.1% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
13.4%
4.6 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 15.6% · Q3 25.0% · Q4 9.1% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.3%
0.3 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
2.6%
3.2 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.6% · Q3 10.0% · Q4 5.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.5% |
13.5%
5 pts worse
|
19.8%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 19.9% · Q3 12.9% · Q4 13.6% · 4Q avg 18.5% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.7%
5.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
84.3%
2.1 pts better
|
81.7%
4.7 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 86.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-01-24 · Fire 2019-01-24
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2017-12-28 · Fire 2017-12-28
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2019-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-13
D · Potential for more than minimal harm
2019-01-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-02-22
D · Potential for more than minimal harm
2019-01-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-02-13
E · Potential for more than minimal harm
2017-12-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-01-22
D · Potential for more than minimal harm
2017-12-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2018-01-05
D · Potential for more than minimal harm
2017-12-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-01-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-15
C · Minimal harm
2019-01-24
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-02-13
D · Potential for more than minimal harm
2017-12-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-01-19
Penalties and ownership
What sits behind the stars
Ownership
Bueche, Ellen
Operational/Managerial Control · Individual
Bueche, Ellen
Corporate Officer · Individual
Lennon, Bridget
Operational/Managerial Control · Individual
Lennon, Bridget
Corporate Officer · Individual
Rangel, Virginia
Operational/Managerial Control · Individual
Rangel, Virginia
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Arabella Health & Wellness Of Mobile
Mobile, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Ashland Place Health And Rehabilitation, LLC
Mobile, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Palm Gardens Health And Rehabilitation, LLC
Mobile, AL
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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