Geneva, AL

Wiregrass Rehabilitation Center & Nursing Home

4-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1200 Maple Avenue West, Geneva, AL

(334) 684-3655

Compare this facility

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

96

Certified beds

Average residents

65

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1977-04-01

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

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.62

Registered nurse staffing · state 0.64 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.51

Nurse aide staffing · state 2.50 · national 2.35

Total nurse hours

3.98

All reported nurse hours · state 3.91 · national 3.89

Licensed hours

1.48

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.27

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

0.78

CMS adjusted RN staffing hours

Adjusted total hours

5.02

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

42%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

726

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

64.80

Composite VBP score used to determine payment impact.

Payment multiplier

1.0192

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

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.96

Baseline 27.91% · Performance 51.58% · Measure score 2.96 · Achievement 2.96 · Improvement 0

Adjusted total nurse staffing

10

Baseline 4.73 hours · Performance 5.98 hours · Measure score 10 · Achievement 10 · Improvement 9

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 5 · 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 9 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 9 · 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 6 · 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 131
Staff flu vaccination coverage	44.85%	42% 2.9 pts better	Numerator 74 · Denominator 165
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
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 4 · 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	1.1	2.0 0.9 pts better	1.9 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.7 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	91.3% 8.7 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	5.1%	3.4% 1.7 pts worse	3.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.7% · Q3 3.1% · Q4 6.3% · 4Q avg 5.1% · 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	6.4%	5.3% 1.1 pts worse	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 5.5% · Q4 13.5% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.4%	24.9% 3.5 pts worse	19.6% 8.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 28.6% · Q3 28.6% · Q4 30.9% · 4Q avg 28.4%
Percentage of long-stay residents who received an antipsychotic medication	13.0%	22.8% 9.8 pts better	16.7% 3.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 14.0% · Q3 8.9% · Q4 11.9% · 4Q avg 13.0% · 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	3.6%	14.8% 11.2 pts better	16.3% 12.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 3.1% · Q3 2.7% · Q4 2.6% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.7%	13.4% 8.7 pts better	14.9% 10.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.7% · Q3 7.5% · Q4 5.8% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.3% 0.7 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.6% 2.6 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	5.1%	13.5% 8.4 pts better	19.8% 14.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 1.5% · Q3 4.1% · Q4 9.0% · 4Q avg 5.1%
Percentage of long-stay residents with pressure ulcers	9.3%	5.7% 3.6 pts worse	5.1% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.1% · Q3 10.9% · Q4 12.5% · 4Q avg 9.3% · 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 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2022-03-24 · Fire 2022-03-24

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2020-01-09 · Fire 2020-01-09

3 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2018-12-20 · Fire 2018-12-20

5 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2022-03-24

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2022-05-04

D · Potential for more than minimal harm 2022-03-24

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-05-04

D · Potential for more than minimal harm 2022-03-24

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-05-04

D · Potential for more than minimal harm 2022-03-24

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2022-05-04

D · Potential for more than minimal harm 2020-01-09

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-02-18

E · Potential for more than minimal harm 2018-12-20

K907 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure medical gas and vacuum systems have documented maintenance programs.

Corrected 2019-01-30

E · Potential for more than minimal harm 2018-12-20

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2019-01-30

Inspection history

Recent health citations

F · Potential for more than minimal harm 2022-03-24

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 2022-04-28

D · Potential for more than minimal harm 2022-03-24

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 2022-04-28

F · Potential for more than minimal harm 2020-01-09

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 2020-02-13

D · Potential for more than minimal harm 2020-01-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-02-13

D · Potential for more than minimal harm 2020-01-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-03-04

F · Potential for more than minimal harm 2018-12-20

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 2019-01-21

D · Potential for more than minimal harm 2018-12-20

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2019-01-21

D · Potential for more than minimal harm 2018-12-20

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 2019-01-21

D · Potential for more than minimal harm 2018-12-20

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 2019-01-21

D · Potential for more than minimal harm 2018-12-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-01-21

Penalties and ownership