Cycle 1
Health 2023-08-24 · Fire 2023-08-24
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Birmingham, AL
South Health And Rehabilitation, LLC
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
1220 South 17th Street, Birmingham, AL
(205) 933-2180
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1976-10-01
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
0.62
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.34
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
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · 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 14 · 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 3 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 3 · 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 69 |
| Staff flu vaccination coverage | 13.91% |
42%
28.1 pts worse
|
Numerator 16 · Denominator 115 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
91.3%
5.5 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 95.1% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.8% |
94.8%
2 pts worse
|
95.5%
2.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.4%
0.6 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.9% · Q3 3.2% · Q4 4.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
1.3%
0.3 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.3%
3.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.7% · Q3 1.9% · Q4 1.6% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
24.9%
8.5 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 18.6% · Q3 15.1% · Q4 16.4% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
22.8%
6.4 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 10.5% · Q3 18.8% · Q4 18.4% · 4Q avg 16.4% · 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 | 22.5% |
14.8%
7.7 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
13.4%
9.4 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 24.5% · Q3 13.3% · Q4 17.3% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.6%
1.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.6% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.3% |
13.5%
2.2 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 14.7% · Q3 9.1% · Q4 8.3% · 4Q avg 11.3% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.7%
1.9 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 6.1% · Q3 7.8% · Q4 4.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
84.3%
3.3 pts worse
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.7% · Q2 82.0% · Q3 82.0% · Q4 91.7% · 4Q avg 81.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
2.1%
2 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 10.3% · Q3 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.0% |
80.3%
20.3 pts worse
|
79.7%
19.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-29 · Fire 2021-07-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-05-20 · Fire 2019-05-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-01
F · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-01
E · Potential for more than minimal harm
2019-05-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-07-03
Inspection history
Recent health citations
G · Actual harm
2023-08-24
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 2023-04-14
G · Actual harm
2023-08-24
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 2023-04-14
D · Potential for more than minimal harm
2023-08-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-25
D · Potential for more than minimal harm
2021-07-29
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 2021-09-02
D · Potential for more than minimal harm
2019-05-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-24
D · Potential for more than minimal harm
2019-05-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-24
Penalties and ownership
What sits behind the stars
$4,245
2023-08-24
Fine
Fine · fine $4,245
Fine
$4,324
2023-08-24
Fine
Fine · fine $4,324
Fine
$0
2023-08-24
Payment Denial
Payment Denial · denial start 2023-09-23 · 8 days
8 day denial
Ownership
Nhs Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Berkadia Commercial Mortgage LLC
5% Or Greater Security Interest · Organization
Berkadia Commercial Mortgage LLC
5% Or Greater Mortgage Interest · Organization
Estes, James
Corporate Officer · Individual
Holmes, Letchernique
Operational/Managerial Control · Individual
Holmes, Letchernique
Corporate Director · Individual
Lewis, Cynthia
Operational/Managerial Control · Individual
Lewis, Cynthia
W-2 Managing Employee · Individual
Long, Phillip
Corporate Officer · Individual
Patterson, Derek
Operational/Managerial Control · Individual
Patterson, Derek
Corporate Director · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
South Health Realty, LLC
5% Or Greater Security Interest · Organization
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#3
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