Cycle 1
Health 2022-07-14 · Fire 2022-07-14
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
South Haven Health And Rehabilitation, LLC
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3141 Old Columbiana Road, Birmingham, AL
(205) 822-1580
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
101
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1971-11-01
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
0.70
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
2.47
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.43
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,191
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
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
7.27
Baseline 10.31% · Performance 6.18% · Measure score 7.27 · Achievement 5.53 · Improvement 7.27
Total nurse turnover
1.39
Performance 58.00% · Measure score 1.39 · Achievement 1.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.63
Baseline 3.39 hours · Performance 4.11 hours · Measure score 3.63 · Achievement 3.63 · Improvement 2.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 2.44% · Lower 95% interval 5.94% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.65% |
95.27%
0.4 pts better
|
Numerator 22 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 1 · Denominator 23 · Adjusted rate 3.37% |
| Healthcare-associated infections requiring hospitalization | 6.18% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 85 |
| Staff flu vaccination coverage | 10% |
42%
32 pts worse
|
Numerator 17 · Denominator 170 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| 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 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 30.0% |
91.3%
61.3 pts worse
|
93.4%
63.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 25.6% · Q3 32.9% · Q4 31.0% · 4Q avg 30.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.8% |
94.8%
26 pts worse
|
95.5%
26.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 4.3% · Q4 2.3% · 4Q avg 2.2% · 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 | 3.6% |
5.3%
1.7 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.8% |
24.9%
13.9 pts worse
|
19.6%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 35.9% · Q3 46.4% · Q4 40.8% · 4Q avg 38.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.4% |
22.8%
13.6 pts worse
|
16.7%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 48.0% · Q3 35.1% · Q4 31.4% · 4Q avg 36.4% · 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 | 18.4% |
14.8%
3.6 pts worse
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
13.4%
7.9 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 28.3% · Q3 20.0% · Q4 8.9% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.3%
1.6 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.9% · Q3 1.5% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.7% · Q3 4.4% · Q4 0.0% · 4Q avg 1.9% · 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 4.8% · Q2 7.3% · Q3 12.8% · Q4 12.9% · 4Q avg 9.1% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
5.7%
1.4 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.3% · Q3 3.8% · Q4 4.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.8% |
84.3%
59.5 pts worse
|
81.7%
56.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 14.7% · Q3 38.2% · Q4 20.3% · 4Q avg 24.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.5%
5.4 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.5% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.1%
0.4 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.8% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 16.9% |
80.3%
63.4 pts worse
|
79.7%
62.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 16.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
24.5%
3.9 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 25.8% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-20 · Fire 2019-06-20
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-07-03 · Fire 2018-07-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-07-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-23
D · Potential for more than minimal harm
2022-07-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-23
D · Potential for more than minimal harm
2019-06-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-07-29
D · Potential for more than minimal harm
2019-06-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-07-29
D · Potential for more than minimal harm
2019-06-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-29
E · Potential for more than minimal harm
2018-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-08-07
D · Potential for more than minimal harm
2018-07-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-08-14
D · Potential for more than minimal harm
2018-07-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-08-14
D · Potential for more than minimal harm
2018-07-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-08-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-16
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 2024-05-21
D · Potential for more than minimal harm
2024-04-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-21
E · Potential for more than minimal harm
2022-07-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-18
F · Potential for more than minimal harm
2019-06-20
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 2019-07-25
F · Potential for more than minimal harm
2019-06-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-07-25
D · Potential for more than minimal harm
2019-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-25
F · Potential for more than minimal harm
2018-07-03
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 2018-08-07
D · Potential for more than minimal harm
2018-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-07
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
Cobb, Leigh
Operational/Managerial Control · Individual
Cobb, Leigh
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Jordan, Hilton
Operational/Managerial Control · Individual
Long, Phillip
Corporate Officer · Individual
Morris, Hilary
Operational/Managerial Control · Individual
Morris, Hilary
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
South Haven Health Realty LLC
5% Or Greater Security Interest · Organization
Nearby options
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#3
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