Cycle 1
Health 2022-04-22 · Fire 2022-04-22
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Madison, AL
Valley View Health And Rehabilitation, LLC
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5968 Wall Triana Highway, Madison, AL
(256) 830-2316
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
136
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
1996-03-19
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
0.55
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.81
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
3.72
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.31
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,918
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0077
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.47
Baseline 24.33% · Performance 18.51% · Measure score 7.47 · Achievement 6.31 · Improvement 7.47
Healthcare-associated infections
7.76
Baseline 7.50% · Performance 5.51% · Measure score 7.76 · Achievement 7.76 · Improvement 7.43
Total nurse turnover
0
Performance 82.19% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.98
Baseline 3.93 hours · Performance 4.78 hours · Measure score 5.98 · Achievement 5.98 · Improvement 4.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 483 · Observed rate 8.7% · Lower 95% interval 7.44% |
| Discharge to community | 64.18% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 452 · Observed rate 59.07% · Lower 95% interval 58.84% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.63% |
95.27%
4.4 pts better
|
Numerator 267 · Denominator 268 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 3 · Denominator 268 |
| Discharge self-care score | 44.89% |
53.69%
8.8 pts worse
|
Numerator 79 · Denominator 176 |
| Discharge mobility score | 35.23% |
50.94%
15.7 pts worse
|
Numerator 62 · Denominator 176 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 4 · Denominator 268 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 5.52% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 3.95% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 8.7% |
8.2%
0.5 pts better
|
Numerator 8 · Denominator 92 |
| Staff flu vaccination coverage | 18.87% |
42%
23.1 pts worse
|
Numerator 50 · Denominator 265 |
| Discharge function score | 40.91% |
56.45%
15.5 pts worse
|
Numerator 72 · Denominator 176 |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 60 · Denominator 63 |
| Transfer of health information to patient | 94.41% |
96.28%
1.9 pts worse
|
Numerator 152 · Denominator 161 |
| Resident COVID-19 vaccinations up to date | 28.81% |
25.2%
3.6 pts better
|
Numerator 34 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.3%
8.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.8%
4.2 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.4%
1.8 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 2.1% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
1.3%
4 pts worse
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.6% · Q3 3.5% · Q4 3.4% · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.3%
1.8 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.0% · Q3 2.7% · Q4 4.9% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
24.9%
12.4 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 15.6% · Q3 11.7% · Q4 13.1% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
22.8%
13.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 10.9% · Q3 6.5% · Q4 1.6% · 4Q avg 8.9% · 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 | 13.6% |
14.8%
1.2 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 15.8% · Q3 0.0% · Q4 8.3% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
13.4%
3.6 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 12.9% · Q3 8.6% · Q4 5.3% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.6%
2.3 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.6% |
13.5%
4.9 pts better
|
19.8%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 10.6% · Q3 13.4% · Q4 1.1% · 4Q avg 8.6% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.7%
2 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.9% · Q3 6.5% · Q4 3.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
84.3%
8.8 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 90.1% · Q3 97.5% · Q4 97.3% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.5%
3.7 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.1%
0.9 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 1.5% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
80.3%
6.9 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
24.5%
1.8 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 24.3% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-22 · Fire 2019-08-22
2 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-07-12 · Fire 2018-07-12
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-04-22
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
D · Potential for more than minimal harm
2022-04-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-06-01
E · Potential for more than minimal harm
2019-08-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-10-01
E · Potential for more than minimal harm
2019-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-22
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2019-10-01
D · Potential for more than minimal harm
2018-07-12
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 2018-08-21
D · Potential for more than minimal harm
2018-07-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-08-21
D · Potential for more than minimal harm
2018-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-08-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-22
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 2022-05-27
D · Potential for more than minimal harm
2022-04-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-04-22
F761 · Pharmacy Service Deficiencies
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 2022-05-27
D · Potential for more than minimal harm
2019-08-22
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-09-26
D · Potential for more than minimal harm
2019-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-26
F · Potential for more than minimal harm
2018-07-12
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 2018-08-16
D · Potential for more than minimal harm
2018-07-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2018-08-16
C · Minimal harm
2018-07-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-08-16
Penalties and ownership
What sits behind the stars
Ownership
Millennium Health 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
Cox, Tammy
Operational/Managerial Control · Individual
Cox, Tammy
Corporate Director · Individual
Estes, James
Corporate Officer · Individual
Long, Phillip
Corporate Officer · Individual
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Valley View Health Realty LLC
5% Or Greater Security Interest · Organization
Ward, Sonny
Operational/Managerial Control · Individual
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#3
Brookshire Healthcare Center
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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