Cycle 1
Health 2024-04-17 · Fire 2024-04-17
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
Northway Health And Rehabilitation, LLC
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
Facility snapshot
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
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
0.29
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
0.96
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,385
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
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
2.99
Performance 51.46% · Measure score 2.99 · Achievement 2.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.05
Baseline 4.72 hours · Performance 4.51 hours · Measure score 5.05 · Achievement 5.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · 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 7 · 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 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 21.21% |
42%
20.8 pts worse
|
Numerator 35 · Denominator 165 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| 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 | 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 2 · 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 | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| 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 · Adjusted 2.3 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 68.6% · Q2 37.1% · Q3 21.9% · Q4 19.0% · 4Q avg 36.7% |
| 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 · 4Q avg 95.4% |
| 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 · Q1 1.9% · Q2 2.9% · Q3 2.9% · Q4 2.9% · 4Q avg 2.6% · 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 | 4.1% |
5.3%
1.2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.2% · Q3 2.1% · Q4 1.0% · 4Q avg 4.1% |
| 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 · Q1 22.0% · Q2 18.6% · Q3 25.8% · Q4 24.7% · 4Q avg 22.8% |
| 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 · Q1 33.8% · Q2 39.4% · Q3 40.0% · Q4 36.8% · 4Q avg 37.5% · 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 | 17.1% |
14.8%
2.3 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 40.2% · Q3 15.6% · Q4 7.3% · 4Q avg 17.1% · Used in QM five-star |
| 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 · Q1 11.3% · Q2 32.6% · Q3 15.8% · Q4 6.4% · 4Q avg 16.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| 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 · Q1 3.5% · Q2 5.4% · Q3 18.7% · Q4 4.1% · 4Q avg 7.9% |
| 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 · Q1 4.7% · Q2 4.9% · Q3 3.0% · Q4 2.3% · 4Q avg 3.7% · Used in QM five-star |
| 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 · Q1 45.0% · Q2 18.2% · Q3 17.4% · Q4 23.1% · 4Q avg 25.3% |
| 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 | 76.0% |
80.3%
4.3 pts worse
|
79.7%
3.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-23 · Fire 2019-05-23
2 health deficiencies
Top issue: Infection Control (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2018-06-07 · Fire 2018-06-07
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-17
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-17
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 2024-05-29
D · Potential for more than minimal harm
2024-04-17
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-04-17
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 2024-05-29
D · Potential for more than minimal harm
2024-04-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-29
E · Potential for more than minimal harm
2019-05-23
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-28
E · Potential for more than minimal harm
2019-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
D · Potential for more than minimal harm
2018-06-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-07-06
D · Potential for more than minimal harm
2018-06-07
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 2018-07-06
D · Potential for more than minimal harm
2018-06-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-07-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-04-17
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-17
F584 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2024-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-17
F842 · Resident Assessment and Care Planning Deficiencies
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
C · Minimal harm
2024-04-17
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-05-22
D · Potential for more than minimal harm
2019-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-24
F · Potential for more than minimal harm
2018-06-07
F809 · Nutrition and Dietary Deficiencies
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
F · Potential for more than minimal harm
2018-06-07
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 2018-07-06
D · Potential for more than minimal harm
2018-06-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-07-19
Penalties and ownership
What sits behind the stars
Ownership
Northport Holding Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Capital Funding LLC
5% Or Greater Security Interest · Organization
Capital Funding LLC
5% Or Greater Mortgage Interest · Organization
Estes, James
Corporate Officer · Individual
Holding Facilities Group LLC
5% Or Greater Security Interest · Organization
Holmes, Letchernique
Operational/Managerial Control · Individual
Holmes, Letchernique
Corporate Director · Individual
Kilgore, Jordan
Operational/Managerial Control · Individual
Kilgore, Jordan
W-2 Managing Employee · Individual
Long, Phillip
Corporate Officer · Individual
Northway Health Realty LLC
5% Or Greater Security Interest · Organization
Patterson, Derek
Operational/Managerial Control · Individual
Patterson, Derek
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Civic Center Health And Rehabilitation, LLC
Birmingham, AL
3-star overall rating with 2-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Greenbriar At The Altamont Skilled Nursing Facilit
Birmingham, AL
3-star overall rating with 3-star inspections with 1 recent health deficiencies
#3
South Health And Rehabilitation, LLC
Birmingham, AL
1-star overall rating with 2-star inspections with $8,569 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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