Cycle 1
Health 2024-02-09 · Fire 2024-02-09
13 health deficiencies
Top issue: Resident Rights (6 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Jasper, AL
Shadescrest Health Care Center
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
331 West 25th Street, Jasper, AL
(205) 384-9086
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-12-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.69
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
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
0.77
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,602
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.66% · Performance 21.67% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.27% · Performance 8.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.91
Performance 35.42% · Measure score 6.91 · Achievement 6.91 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.58
Baseline 3.97 hours · Performance 4.10 hours · Measure score 3.58 · Achievement 3.58 · Improvement 0.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 7.69% · Lower 95% interval 6.82% |
| Discharge to community | 40.51% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 27.5% · Lower 95% interval 27.43% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 41 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 65.38% |
53.69%
11.7 pts better
|
Numerator 17 · Denominator 26 |
| Discharge mobility score | 57.69% |
50.94%
6.8 pts better
|
Numerator 15 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.04% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 6.72% |
8.2%
1.5 pts worse
|
Numerator 9 · Denominator 134 |
| Staff flu vaccination coverage | 80.49% |
42%
38.5 pts better
|
Numerator 165 · Denominator 205 |
| Discharge function score | 57.69% |
56.45%
1.2 pts better
|
Numerator 15 · Denominator 26 |
| 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 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 3.3 |
2.0
1.3 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.7 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.4%
0.1 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.2% · Q3 4.8% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
1.3%
About the same
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.3%
0.1 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 10.9% · Q3 1.6% · Q4 6.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
24.9%
9.8 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 35.1% · Q3 32.3% · Q4 35.7% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.8% |
22.8%
14 pts worse
|
16.7%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 38.2% · Q3 34.9% · Q4 32.0% · 4Q avg 36.8% · 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 | 17.8% |
14.8%
3 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 21.2% · Q3 13.4% · Q4 8.3% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
13.4%
2 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 15.4% · Q3 8.5% · Q4 9.4% · 4Q avg 11.4% · 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 1.6% · Q2 0.0% · 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 | 2.4% |
2.6%
0.2 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.3% · Q3 1.2% · Q4 1.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.7% |
13.5%
6.8 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 8.5% · Q3 5.2% · Q4 3.4% · 4Q avg 6.7% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.7%
4.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.9% · Q3 1.9% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
84.3%
12.7 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.6% · Q3 97.2% · Q4 95.6% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
11.5%
0.1 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 12.8% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.1%
0.3 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
80.3%
18.3 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 44.1% |
24.5%
19.6 pts worse
|
23.9%
20.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 44.1% · Observed 43.6% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-01 · Fire 2019-08-01
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-06-26 · Fire 2018-06-26
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-20
E · Potential for more than minimal harm
2019-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-13
D · Potential for more than minimal harm
2019-08-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-13
D · Potential for more than minimal harm
2019-08-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-02-09
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 2024-03-15
E · Potential for more than minimal harm
2024-02-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-09
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 2024-03-15
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
C · Minimal harm
2024-02-09
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-03-15
C · Minimal harm
2024-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-15
B · Minimal harm
2024-02-09
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 2024-03-15
D · Potential for more than minimal harm
2019-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-30
C · Minimal harm
2019-08-01
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 2019-09-30
D · Potential for more than minimal harm
2018-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-31
Penalties and ownership
What sits behind the stars
Ownership
King, Janet
5% Or Greater Direct Ownership Interest · Individual
Stout, Jerry
5% Or Greater Direct Ownership Interest · Individual
Davis, Richard
Operational/Managerial Control · Individual
Estill, Jennifer
Operational/Managerial Control · Individual
Free, Joyce
Operational/Managerial Control · Individual
Frye, Jean
Operational/Managerial Control · Individual
Harrison, Boyde
Operational/Managerial Control · Individual
Kenyon, Amanda
Operational/Managerial Control · Individual
King, Janet
Corporate Director · Individual
Kolb, Sarah
Operational/Managerial Control · Individual
Mitchell Kelley, Kimberly
Operational/Managerial Control · Individual
Mumpower, Robert
Operational/Managerial Control · Individual
Nexus Resource Group
Operational/Managerial Control · Organization
Polm, Terri
Operational/Managerial Control · Individual
Sims, Brenda
Operational/Managerial Control · Individual
Stout, Jerry
Operational/Managerial Control · Individual
Stout, Jerry
Corporate Director · Individual
Tidwell, Bethany
Operational/Managerial Control · Individual
West, Mark
Operational/Managerial Control · Individual
West, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Ridgewood Health Services, Inc.
Jasper, AL
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ridgeview Health Services, Inc
Jasper, AL
2-star overall rating with 2-star inspections with $13,520 in total fines with 5 recent health deficiencies
#3
Cordova Health And Rehabilitation, LLC
Cordova, AL
1-star overall rating with 1-star inspections with abuse icon flag with $76,242 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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