Eight Mile, AL

Pine Haven Rehabilitation And Wellness Center

2-star overall rating with 2-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

4525 St Stephens Road, Eight Mile, AL

(251) 452-0996

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

172

Certified beds

Average residents

145

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Norbert Bennett & Donald Denz

Operator or chain grouping

Approved since

1978-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

29 facilities

Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars

Changed ownership

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

0.37

Registered nurse staffing · state 0.64 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.25

Nurse aide staffing · state 2.50 · national 2.35

Total nurse hours

3.22

All reported nurse hours · state 3.91 · national 3.89

Licensed hours

0.97

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

2.97

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.36 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.43

CMS adjusted RN staffing hours

Adjusted total hours

3.81

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,917

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.05

Composite VBP score used to determine payment impact.

Payment multiplier

0.9828

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.69

Baseline 21.03% · Performance 19.72% · Measure score 3.69 · Achievement 3.69 · Improvement 2.77

Healthcare-associated infections

Baseline 7.09% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.28

Baseline 54.62% · Performance 54.37% · Measure score 2.28 · Achievement 2.28 · Improvement 0

Adjusted total nurse staffing

2.85

Baseline 3.28 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 1.93

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.83%	10.72% 0.9 pts better	No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 6.18%
Discharge to community	54.89%	50.57% 4.3 pts better	No Different than the National Rate · Eligible stays 31 · Observed rate 45.16% · Lower 95% interval 41.41%
Medicare spending per beneficiary	1.22	1.02 0.2 pts worse
Drug regimen review with follow-up	76.47%	95.27% 18.8 pts worse	Numerator 39 · Denominator 51
Falls with major injury	7.84%	0.77% 7.1 pts worse	Numerator 4 · Denominator 51
Discharge self-care score	30.56%	53.69% 23.1 pts worse	Numerator 11 · Denominator 36
Discharge mobility score	22.22%	50.94% 28.7 pts worse	Numerator 8 · Denominator 36
Pressure ulcers or injuries, new or worsened	5.88%	2.29% 3.6 pts worse	Numerator 3 · Denominator 51 · Adjusted rate 5.09%
Healthcare-associated infections requiring hospitalization	8.19%	7.12% 1.1 pts worse	No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 4.41%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 184
Staff flu vaccination coverage	14.81%	42% 27.2 pts worse	Numerator 40 · Denominator 270
Discharge function score	22.22%	56.45% 34.2 pts worse	Numerator 8 · Denominator 36
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	33.33%	25.2% 8.1 pts better	Numerator 9 · Denominator 27

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	2.0 0.4 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	1.8 0.4 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.6%	91.3% 0.7 pts worse	93.4% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 95.0% · Q3 88.9% · Q4 85.8% · 4Q avg 90.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	86.7%	94.8% 8.1 pts worse	95.5% 8.8 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 86.7%
Percentage of long-stay residents experiencing one or more falls with major injury	5.3%	3.4% 1.9 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.2% · Q3 4.2% · Q4 4.3% · 4Q avg 5.3% · 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	5.8%	5.3% 0.5 pts worse	5.4% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.4% · Q3 6.5% · Q4 4.6% · 4Q avg 5.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.1%	24.9% 13.8 pts better	19.6% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.2% · Q3 9.9% · Q4 11.9% · 4Q avg 11.1%
Percentage of long-stay residents who received an antipsychotic medication	45.0%	22.8% 22.2 pts worse	16.7% 28.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 43.8% · Q3 46.7% · Q4 45.1% · 4Q avg 45.0% · 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	9.7%	14.8% 5.1 pts better	16.3% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 4.7% · Q3 6.4% · Q4 0.0% · 4Q avg 9.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.1%	13.4% 1.3 pts better	14.9% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 7.6% · Q3 12.4% · Q4 5.3% · 4Q avg 12.1% · 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 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	2.6% 1.7 pts better	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 1.4% · Q4 0.7% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	9.1%	13.5% 4.4 pts better	19.8% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 7.8% · Q3 7.7% · Q4 8.0% · 4Q avg 9.1%
Percentage of long-stay residents with pressure ulcers	5.8%	5.7% 0.1 pts worse	5.1% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.8% · Q3 5.6% · Q4 5.5% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	57.3%	84.3% 27 pts worse	81.7% 24.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 59.6% · Q3 47.8% · Q4 46.3% · 4Q avg 57.3%
Percentage of short-stay residents who had an outpatient emergency department visit	10.7%	11.5% 0.8 pts better	12.0% 1.3 pts better	Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 12.5% · Expected 13.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	2.1% 0.2 pts better	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	32.7%	80.3% 47.6 pts worse	79.7% 47 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 32.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.2%	24.5% 1.3 pts better	23.9% 0.7 pts better	Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 25.0% · Expected 25.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2022-10-19 · Fire 2022-10-19

9 health deficiencies

Top issue: Resident Assessment and Care Planning (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2021-06-08 · Fire 2021-06-08

8 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2019-04-11 · Fire 2019-04-11

8 health deficiencies

Top issue: Resident Rights (4 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2022-10-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-23

E · Potential for more than minimal harm 2022-10-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

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 2022-11-23

D · Potential for more than minimal harm 2022-10-19

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-11-23

E · Potential for more than minimal harm 2021-06-08

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-06-16

E · Potential for more than minimal harm 2019-04-11

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-05-23

E · Potential for more than minimal harm 2019-04-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-05-23

D · Potential for more than minimal harm 2019-04-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-05-23

D · Potential for more than minimal harm 2019-04-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-05-23

D · Potential for more than minimal harm 2019-04-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-05-24

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-05-31

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 2024-07-05

E · Potential for more than minimal harm 2022-10-19

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 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

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 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-11-23

D · Potential for more than minimal harm 2022-10-19

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 2022-11-23

F · Potential for more than minimal harm 2021-06-08

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 2021-07-09

F · Potential for more than minimal harm 2021-06-08

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2021-07-09

D · Potential for more than minimal harm 2021-06-08

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-07-09

D · Potential for more than minimal harm 2021-06-08

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 2021-07-09

D · Potential for more than minimal harm 2021-06-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2021-07-09

D · Potential for more than minimal harm 2021-06-08

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2021-07-09

D · Potential for more than minimal harm 2021-06-08

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2021-07-09

D · Potential for more than minimal harm 2019-04-11

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2019-05-16

D · Potential for more than minimal harm 2019-04-11

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 2019-05-16

Penalties and ownership