Cycle 1
Health 2022-04-21 · Fire 2022-04-21
2 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
York, AL
Sumter Health And Rehabilitation, L L C
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1505 East 4th Avenue, York, AL
(205) 392-5281
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1967-01-16
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
0.57
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
2.39
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.26
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,624
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.19
Baseline 18.90% · Performance 18.56% · Measure score 6.19 · Achievement 6.19 · Improvement 1.28
Healthcare-associated infections
0
Baseline 7.24% · Performance 8.06% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.47
Performance 41.30% · Measure score 5.47 · Achievement 5.47 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.02
Baseline 3.63 hours · Performance 4.22 hours · Measure score 4.02 · Achievement 4.02 · Improvement 2.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 11.48% · Lower 95% interval 7.71% |
| Discharge to community | 53.02% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 46.94% · Lower 95% interval 40.43% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.12% |
95.27%
0.1 pts worse
|
Numerator 39 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 15 · Denominator 25 |
| Discharge mobility score | 52% |
50.94%
1.1 pts better
|
Numerator 13 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 7.32% |
2.29%
5 pts worse
|
Numerator 3 · Denominator 41 · Adjusted rate 6.92% |
| Healthcare-associated infections requiring hospitalization | 8.06% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 10.81% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 10.11% |
8.2%
1.9 pts better
|
Numerator 9 · Denominator 89 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 40 · Denominator 240 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 16 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 0.9 |
2.0
1.1 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.3%
8.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 2.4% |
3.4%
1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.1% · Q3 2.1% · Q4 2.1% · 4Q avg 2.4% · 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 | 0.9% |
5.3%
4.4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
24.9%
6.1 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.0% · Q3 19.3% · Q4 19.0% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.3% |
22.8%
0.5 pts worse
|
16.7%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 23.6% · Q3 23.6% · Q4 20.3% · 4Q avg 23.3% · 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 | 6.0% |
14.8%
8.8 pts better
|
16.3%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.4% · Q3 6.4% · Q4 8.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
13.4%
4.9 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.5% · Q3 9.6% · Q4 7.9% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.3%
1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.6%
2.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.6% |
13.5%
8.9 pts better
|
19.8%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.0% · Q3 4.1% · Q4 3.1% · 4Q avg 4.6% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.7%
2.2 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 10.4% · Q3 7.6% · Q4 6.3% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
11.5%
5.3 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 17.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
2.1%
0.5 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 3.7% · Q4 2.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
80.3%
15.4 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 4.6% |
24.5%
19.9 pts better
|
23.9%
19.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.3% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-05 · Fire 2019-09-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-04-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-21
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 2022-06-01
E · Potential for more than minimal harm
2019-09-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-14
E · Potential for more than minimal harm
2019-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-14
E · Potential for more than minimal harm
2019-09-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-10-14
E · Potential for more than minimal harm
2019-09-05
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 2019-10-14
D · Potential for more than minimal harm
2019-09-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-14
E · Potential for more than minimal harm
2018-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-09-10
D · Potential for more than minimal harm
2018-08-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-09-06
D · Potential for more than minimal harm
2018-08-16
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2018-09-10
D · Potential for more than minimal harm
2018-08-16
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2018-08-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-04-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-04-21
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-05-26
F · Potential for more than minimal harm
2019-09-05
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 2019-10-09
D · Potential for more than minimal harm
2019-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-09
F · Potential for more than minimal harm
2018-08-16
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 2018-09-06
F · Potential for more than minimal harm
2018-08-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-09-06
D · Potential for more than minimal harm
2018-08-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-09-06
D · Potential for more than minimal harm
2018-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-06
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
Boyd, Casey
Operational/Managerial Control · Individual
Boyd, Casey
Corporate Director · Individual
Capital Funding LLC
5% Or Greater Security Interest · Organization
Capital Funding LLC
5% Or Greater Mortgage Interest · Organization
Dampeer, Joe
Operational/Managerial Control · Individual
Dampeer, Joe
W-2 Managing Employee · Individual
Duffy, Marcia
Operational/Managerial Control · Individual
Duffy, Marcia
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Holding Facilities Group LLC
5% Or Greater Security Interest · Organization
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Sumter Health Realty LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
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Marion, MS
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#2
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5-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Diversicare Of Meridian
Meridian, MS
2-star overall rating with 2-star inspections with $12,735 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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