Alabaster, AL
3-star overall rating with 3-star inspections with $16,801 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
850 9th Street, Northwest, Alabaster, AL
(205) 663-3859
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
198
Certified beds
Average residents
182
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1976-06-01
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
RN hours / resident day
0.40
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.59
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
3.17
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
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
2,327
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0043
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.43
Baseline 20.56% · Performance 18.92% · Measure score 5.43 · Achievement 5.43 · Improvement 4.16
Healthcare-associated infections
6.19
Baseline 9.62% · Performance 6.53% · Measure score 6.19 · Achievement 4.38 · Improvement 6.19
Total nurse turnover
5.91
Baseline 73.44% · Performance 42.28% · Measure score 5.91 · Achievement 5.24 · Improvement 5.91
Adjusted total nurse staffing
2.54
Baseline 4.25 hours · Performance 3.8 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 11.21% · Lower 95% interval 7.99% |
| Discharge to community | 42.25% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 32.31% · Lower 95% interval 29.67% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 69 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 32 · Denominator 52 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 20 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 7.14% |
2.29%
4.8 pts worse
|
Numerator 5 · Denominator 70 · Adjusted rate 5.32% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 3.77% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 157 |
| Staff flu vaccination coverage | 28.04% |
42%
14 pts worse
|
Numerator 30 · Denominator 107 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 28 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 6 · Denominator 44 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · 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 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
91.3%
7.8 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 99.4% · Q3 100.0% · Q4 98.8% · 4Q avg 99.1% |
| 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 | 5.3% |
3.4%
1.9 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.6% · Q3 6.0% · Q4 4.6% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
1.3%
1.9 pts worse
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.5% · Q3 1.3% · Q4 0.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.3%
0.8 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.1% · Q3 2.9% · Q4 5.7% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.5% |
24.9%
4.6 pts worse
|
19.6%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 28.1% · Q3 31.2% · Q4 30.5% · 4Q avg 29.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
22.8%
6.6 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 12.5% · Q3 18.1% · Q4 17.6% · 4Q avg 16.2% · 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 | 6.2% |
14.8%
8.6 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.3% · Q3 5.1% · Q4 8.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
13.4%
8.1 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 4.5% · Q4 6.7% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.3%
0.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.9% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.6%
1.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 0.0% · Q4 1.7% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
13.5%
4.8 pts worse
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 20.4% · Q3 16.5% · Q4 21.8% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
5.7%
2.6 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.8% · Q3 10.0% · Q4 8.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
84.3%
0.1 pts worse
|
81.7%
2.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 82.0% · Q3 86.3% · Q4 84.5% · 4Q avg 84.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.5%
2.7 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.4% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
2.1%
1.7 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.2% · Q3 3.6% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
80.3%
6.1 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
24.5%
9.2 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 32.1% · Expected 22.7% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-01
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-01
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-24
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-24
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-30
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-30
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-05-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-22
Health
Post nurse staffing information every day.
Corrected 2024-02-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-11-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-18
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 2022-11-18
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-12
Penalties and ownership
Fine · fine $8,400
Fine
Fine · fine $8,401
Fine
Payment Denial · denial start 2024-06-01 · 90 days
90 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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Birmingham, AL
3-star overall rating with 2-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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