Cycle 1
Health 2021-07-29 · Fire 2021-07-29
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Luverne, AL
Luverne Health And Rehabilitation, LLC
4-star overall rating with 4-star inspections with 2 recent health deficiencies
142 West Third Street, Luverne, AL
(334) 335-6528
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
151
Certified beds
Average residents
136
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1973-10-16
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
0.36
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.23
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,400
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0121
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.82
Baseline 20.17% · Performance 18.27% · Measure score 6.82 · Achievement 6.82 · Improvement 5.54
Healthcare-associated infections
5.95
Baseline 6.74% · Performance 6.06% · Measure score 5.95 · Achievement 5.95 · Improvement 3.41
Total nurse turnover
4.46
Performance 45.45% · Measure score 4.46 · Achievement 4.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.56
Baseline 4.16 hours · Performance 4.66 hours · Measure score 5.56 · Achievement 5.56 · Improvement 2.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 7.81% · Lower 95% interval 6.93% |
| Discharge to community | 41.77% |
50.57%
8.8 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 35.63% · Lower 95% interval 32.12% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 43.33% |
53.69%
10.4 pts worse
|
Numerator 13 · Denominator 30 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 12 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 2.74% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 138 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 157 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 18 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · 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 1.8 · Expected 1.6 · 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 | 30.2% |
94.8%
64.6 pts worse
|
95.5%
65.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 30.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.4%
About the same
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 2.5% · Q4 3.3% · 4Q avg 3.4% · 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 | 2.9% |
5.3%
2.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.0% · Q3 1.0% · Q4 3.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.1% |
24.9%
12.2 pts worse
|
19.6%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 38.1% · Q3 40.6% · Q4 36.3% · 4Q avg 37.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 44.6% |
22.8%
21.8 pts worse
|
16.7%
27.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 44.9% · Q3 40.6% · Q4 47.1% · 4Q avg 44.6% · 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 | 11.7% |
14.8%
3.1 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 20.8% · Q3 9.1% · Q4 4.4% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
13.4%
2.8 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 23.4% · Q3 15.9% · Q4 9.9% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.3%
0.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 long-stay residents with new or worsened bowel or bladder incontinence | 8.0% |
13.5%
5.5 pts better
|
19.8%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.3% · Q3 9.0% · Q4 5.4% · 4Q avg 8.0% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
5.7%
4.7 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 15.1% · Q3 9.4% · Q4 8.1% · 4Q avg 10.4% · 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 | 11.9% |
11.5%
0.4 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
2.1%
2.3 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.6% · Q3 4.2% · Q4 3.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 1.2% |
80.3%
79.1 pts worse
|
79.7%
78.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 1.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
24.5%
5.4 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 16.1% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-19 · Fire 2019-12-19
2 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-01-16 · Fire 2019-01-16
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2019-12-19
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 2020-02-07
E · Potential for more than minimal harm
2019-12-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-02-07
E · Potential for more than minimal harm
2019-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-02-07
D · Potential for more than minimal harm
2019-12-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-07
E · Potential for more than minimal harm
2019-01-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-02-27
E · Potential for more than minimal harm
2019-01-16
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-02-27
E · Potential for more than minimal harm
2019-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2021-07-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-09-01
D · Potential for more than minimal harm
2021-07-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-09-01
D · Potential for more than minimal harm
2019-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-23
D · Potential for more than minimal harm
2019-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-01-16
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 2019-02-20
F · Potential for more than minimal harm
2019-01-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-02-20
D · Potential for more than minimal harm
2019-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-02-20
C · Minimal harm
2019-01-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-02-20
Penalties and ownership
What sits behind the stars
Ownership
Nhs Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Estes, James
Corporate Officer · Individual
Howell, Rhonda
Operational/Managerial Control · Individual
Howell, Rhonda
Corporate Director · Individual
Long, Phillip
Corporate Officer · Individual
Luverne Health Realty LLC
5% Or Greater Security Interest · Organization
Maddox, Mary
Operational/Managerial Control · Individual
Maddox, Mary
W-2 Managing Employee · Individual
Nhs Facilities Group LLC
5% Or Greater Security Interest · Organization
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Richburg, Julie
Operational/Managerial Control · Individual
Richburg, Julie
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Troy Health & Rehabilitation Center
Troy, AL
1-star overall rating with 1-star inspections with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Elba Nursing And Rehabilitation Center, LLC
Elba, AL
1-star overall rating with 2-star inspections with 4 recent health deficiencies
#3
Crowne Health Care Of Greenville
Greenville, AL
4-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
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