Cycle 1
Health 2021-10-07 · Fire 2021-10-07
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Moundville, AL
Moundville Health And Rehabilitation, LLC
4-star overall rating with 4-star inspections
Third Avenue, Moundville, AL
(205) 371-2252
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1977-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.70
Licensed practical nurse staffing
Aide hours / resident day
2.59
Nurse aide staffing
Weekend hours
3.44
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.4%
1.9 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.3%
0.4 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.0% |
24.9%
20.1 pts worse
|
19.6%
25.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
22.8%
1.1 pts better
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.2% |
14.8%
2.6 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
13.4%
3.9 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
13.5%
1.4 pts worse
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.7%
2.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
2.1%
1.6 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-04 · Fire 2019-04-04
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-03-22 · Fire 2018-03-22
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-04-04
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-05-13
E · Potential for more than minimal harm
2019-04-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-13
D · Potential for more than minimal harm
2019-04-04
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 2019-05-13
D · Potential for more than minimal harm
2019-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-13
D · Potential for more than minimal harm
2019-04-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-05-13
D · Potential for more than minimal harm
2019-04-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-13
D · Potential for more than minimal harm
2018-03-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-05-03
D · Potential for more than minimal harm
2018-03-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-05-03
C · Minimal harm
2018-03-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-05-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2019-04-04
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 2019-05-09
D · Potential for more than minimal harm
2019-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-09
D · Potential for more than minimal harm
2019-04-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-05-09
D · Potential for more than minimal harm
2019-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-09
D · Potential for more than minimal harm
2019-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-09
C · Minimal harm
2019-04-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-05-09
D · Potential for more than minimal harm
2018-03-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-04-26
D · Potential for more than minimal harm
2018-03-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2018-04-26
D · Potential for more than minimal harm
2018-03-22
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 2018-04-26
D · Potential for more than minimal harm
2018-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-04-26
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
Boyd, Casey
Operational/Managerial Control · Individual
Boyd, Casey
Corporate Director · Individual
Duffy, Marcia
Operational/Managerial Control · Individual
Duffy, Marcia
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Milligan, Brett
Operational/Managerial Control · Individual
Milligan, Brett
W-2 Managing Employee · Individual
Moundville Health Realty, LLC
5% Or Greater Security Interest · Organization
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
Servisfirst Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
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Heritage Health Care & Rehab Inc
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3-star overall rating with 3-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Aspire Physical Recovery Center Of West Alabama
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4-star overall rating with 4-star inspections
#3
Forest Manor Health And Rehab
Northport, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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