6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1424 North 25th Street, Birmingham, AL
(205) 328-5870
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
113
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1976-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.29
Registered nurse staffing
LPN hours / resident day
0.66
Licensed practical nurse staffing
Aide hours / resident day
2.85
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
| 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 | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 36.7% |
91.3%
54.6 pts worse
|
93.4%
56.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
94.8%
0.6 pts better
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 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 | 4.1% |
5.3%
1.2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
24.9%
2.1 pts better
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 37.5% |
22.8%
14.7 pts worse
|
16.7%
20.8 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 | 17.1% |
14.8%
2.3 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
13.4%
3.1 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.3%
0.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
2.6%
2.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.9% |
13.5%
5.6 pts better
|
19.8%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.7%
2 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.3% |
84.3%
59 pts worse
|
81.7%
56.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.0% |
80.3%
4.3 pts worse
|
79.7%
3.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-05-29
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-29
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-29
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 2024-05-29
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-29
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-29
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-29
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-06-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-28
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-07-06
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 2018-07-06
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-07-06
Inspection history
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-05-22
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-22
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-22
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-22
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-05-22
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-24
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2018-07-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-07-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-07-19
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Mortgage Interest · Organization
Corporate Officer · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
5% Or Greater Security Interest · Organization
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