Cycle 1
Health 2025-02-20 · Fire 2025-02-20
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Hamilton, AL
Marion Regional Nursing Home
4-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
184 Sasser Drive, Hamilton, AL
(205) 921-6340
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
79
Certified beds
Average residents
64
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
North Mississippi Health Services
Operator or chain grouping
Approved since
1977-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 3 overall / 2 health / 4 staffing / 5 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.04
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.51
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
1.15
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
741
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0189
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
8.43
Baseline 52.63% · Performance 29.23% · Measure score 8.43 · Achievement 8.43 · Improvement 7.92
Adjusted total nurse staffing
4.46
Baseline 4.18 hours · Performance 4.35 hours · Measure score 4.46 · Achievement 4.46 · Improvement 0.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · 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 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.38% |
8.2%
1.2 pts better
|
Numerator 6 · Denominator 64 |
| Staff flu vaccination coverage | 56.59% |
42%
14.6 pts better
|
Numerator 73 · Denominator 129 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · 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 5 · 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 | 0.8 |
2.0
1.2 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.3% |
91.3%
10 pts worse
|
93.4%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.3% · Q2 86.9% · Q3 78.9% · Q4 77.0% · 4Q avg 81.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.8%
3.6 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.4%
3 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.3%
0.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.3%
0.1 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 10.0% · Q4 6.5% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.5% |
24.9%
8.6 pts worse
|
19.6%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 33.3% · Q3 39.0% · Q4 32.6% · 4Q avg 33.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
22.8%
0.3 pts worse
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 25.8% · Q3 21.2% · Q4 25.7% · 4Q avg 23.1% · 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 | 21.4% |
14.8%
6.6 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 13.3% · Q4 36.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.7% |
13.4%
12.3 pts worse
|
14.9%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 24.3% · Q3 37.1% · Q4 28.9% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.3%
0.2 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.7% · Q3 1.6% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
13.5%
11.4 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 22.4% · Q3 28.7% · Q4 26.3% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.7%
3 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.8% · Q3 4.5% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.9% |
84.3%
25.4 pts worse
|
81.7%
22.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 42.9% · Q3 58.1% · Q4 79.3% · 4Q avg 58.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.1%
2.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
80.3%
30.3 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-19 · Fire 2019-09-19
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-08-08 · Fire 2018-08-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-11
F · Potential for more than minimal harm
2019-09-19
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-10-29
F · Potential for more than minimal harm
2019-09-19
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2019-10-29
E · Potential for more than minimal harm
2019-09-19
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 2019-10-29
E · Potential for more than minimal harm
2019-09-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-29
E · Potential for more than minimal harm
2019-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-29
D · Potential for more than minimal harm
2019-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-29
F · Potential for more than minimal harm
2018-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-09-18
D · Potential for more than minimal harm
2018-08-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-08-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F758 · Pharmacy Service Deficiencies
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 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
D · Potential for more than minimal harm
2019-09-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-10-23
D · Potential for more than minimal harm
2019-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-23
D · Potential for more than minimal harm
2019-09-19
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-10-23
F · Potential for more than minimal harm
2018-08-08
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 2018-08-23
D · Potential for more than minimal harm
2018-08-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-08-23
D · Potential for more than minimal harm
2018-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-23
Penalties and ownership
What sits behind the stars
Ownership
North Mississippi Health Services Inc
5% Or Greater Indirect Ownership Interest · Organization
Marion Regional Medical Center, Inc.
5% Or Greater Direct Ownership Interest · Organization
Marion Regional Medical Center, Inc.
Operational/Managerial Control · Organization
Nobles, Sharon
Corporate Officer · Individual
Spees, Michael
Operational/Managerial Control · Individual
Toppin, Bruce
Corporate Officer · Individual
Wright, Anna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sunset Manor
Guin, AL
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Diversicare Of Winfield
Winfield, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Haleyville Health Care Center
Haleyville, AL
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
Jump out