Highlands Rehabilitation and Wellness Center
733 Mary Vann Lane, Birmingham, AL 35215 · For profit - Limited Liability company · 132 certified beds · (205) 854-1361 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2024
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- the CMS record shows $24,834 in federal fines (most recent 2024-05-13)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.7% | 12.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.2% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.6% | 3.3% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 5.3% | 12.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 33.3% | 24.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.5% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 8.2% | 12.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.6% | 21.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 80.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.4% | 24.8% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.83 | 1.96 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.62 | 1.70 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.7%CMS range 46.2–80.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 6.1–15.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 132 beds and averages 116.7 residents a day — about 88% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.75 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.28 hrs/resident/day on weekends vs 3.10 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.43 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
14 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · L2024-05-13 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policies titled Quality Improvement Program, and Quality Assurance Performance Improvement Plan the facility's Quality Assurance Performance Improvement (QAPI) committee failed to systemically address all causal factors related to four staff providing Cardiopulmonary Resuscitation (CPR) to Resident Identifier (RI) #159, a resident with Advanced Directive for Do Not Resuscitate (DNR). The QAPI committee further failed to notify the Governing Body of the adverse event. On [DATE] RI #159's end-of-life wishes were not honored. Licensed staff failed to review RI #159's chart for code status prior to CPR. RI #159's nurse was not in the facility at the time of the code but was sitting outside in the car. When RI #159's nurse came onto the building during the code, she did try to review RI #159's record but could not readily and immediately locate the appropriate paperwork to identify RI #159's code status for DNR. All Licensed staff performing CPR on RI #159…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-05-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review, FUNDAMENTALS OF NURSING NINTH EDITION, a complaint received by the Alabama Department of Public Health, the facility's policies titled RESIDENT BILL OF RIGHTS, ADVANCE DIRECTIVES, and Cardio Pulmonary Resuscitation (CPR), the facility failed to honor Resident Identifier (RI) #159's Advanced Directive for end-of-life wishes. RI #159 had an Advanced Directive which directed staff to withhold resuscitative measures in the event of cardiopulmonary cessation and an active physician's order for DNR (Do Not Resuscitate) code status. During the evening shift on [DATE], RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8 around 8:20 PM. The first licensed responder, Registered Nurse (RN) #9 did not check RI #159's code status in accordance with the facility's protocol before she initiated CPR. In addition to RN #9, the CPR Instructor (INST), Licensed Practical Nurse (LPN) #11, and RN #12 participated in the code without verifying RI #159's medical record for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-05-13 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, a complaint recieved by the Alabama Department of Public Health, and the facility policy titled Cardio Pulmonary Resuscitation (CPR) the facility failed to ensure CPR was not initiated for Resident Identifier (RI) #159 on [DATE]. RI #159 had an Advanced Directive directing staff to withhold lifesaving measures including CPR. On [DATE] at approximately 8:20 PM, RI #159 was found by Certified Nursing Assistant (CNA) #8 in respiratory distress, mumbling and appeared pale in color. CNA #8, notified Registered Nurse (RN) #9 who responded and found RI #159 to be unresponsive to sternal rub. RN #9 initiated CPR and instructed CNA #8 to call a Code Blue and summon additional assistance from facility staff. RN #12, RN #9, Licensed Practical Nurse (LPN) #11 and the CPR Instructor (INST) assisted during the code and did not check RI #159's code status. The facility staff performed CPR for approximately 10 minutes until Emergency Medical Services (EMS) arrived at 8:43 PM. EMS provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-05-13 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide sufficient nursing staff to consistently meet the needs of the residents. This deficient practice affected Resident Identifier (RI) #159. The facility failed to ensure the South Unit was properly staffed on [DATE] around 8:20 PM when RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. Two nurses were scheduled to be working on the unit; however, one nurse left early after working nearly 15 hours that day and the other one was in the parking lot. The CNA left the unresponsive resident to summon nurses from another unit who responded by initiating Cardiopulmonary Resuscitation (CPR) without first checking RI #159's medical record for the DNR order that was in effect. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, or impairment to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-05-13 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, a facility document titled Code Blue Evaluation, and the facility CARDIOPULMONARY RESUSCITATION (CPR), the facility failed to ensure the facility provided training and skills verification to staff on their CPR policy. The facility did not implement training and skills verification to ensure all staff were able to respond to an emergent situation according to their policy to verify a resident's code status before initiating CPR. On [DATE] around 8:20 PM RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. The staff who responded initiated CPR without first verifying Resident Identifier (RI) #159's code status in the medical record. Four staff members, Registered Nurse (RN) #12, RN #9, Licensed Practical Nurse (LPN) #11, and the CPR Instructor (INST) assisted during the code and did not check RI #159's code status. As a result of the staff failing to verify RI #159's code status, CPR was provided from approximately 8:20 PM until 9:16 PM. These failures affected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, and review of a facility reported incident, the facility failed to ensure Resident Identifier (RI) #58, a resident with moderate cognitive impairment, was assessed for self-administration of medication before Licensed Practical Nurse (LPN) #13 gave RI #58 a rectal suppository for RI #58 to self-administer on 12/06/2023. This affected RI #58, one of 10 residents for whom medications were reviewed. Findings include: On 12/07/2023 the facility reported to the Alabama Department of Public Health Online Incident Report System an incident involving RI #58 in which RI #58's Resident Representative alleged negligence due to RI #58 being handed a suppository by LPN #13 for RI #58 to self-administer on 12/06/2023. RI #58 was re-admitted to the facility on [DATE] with diagnoses to include: Schizoaffective Disorder (Bipolar Type) and Parkinson's Disease. RI #58's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/08/2023 documented a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-13 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, interviews, the facility investigative file for Resident Identifier (RI) #400, and a facility policy titled Abuse Prevention, the facility failed to ensure RI #400 was free from misappropriation of property when the facility was unable to account for 34 doses of RI #400's Hydrocodone-Acetaminophen Oral Tablet 5.0-325 milligrams (mg). The facility further failed to ensure the residents on the Transitional Care Unit (TCU) were free from misappropriation when Licensed Practical Nurse (LPN) #5 took medications from the TCU medication cart. This had the potential to affect RI #400, one of three residents sampled for abuse and all residents residing on the TCU. This deficiency was cited as a result of the investigation of facility reported incident/complaint/report number AL00048045. Findings include: Review of a facility policy undated titled ABUSE PREVENTION, documented . POLICY: . The facility is committed to protecting the residents from abuse . DEFINITIONS: . Misappropriation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, a review of the facility's pharmacy policy titled, CONTROLLED MEDICATIONS ADMINISTRATION, the facility failed to ensure controlled medication records were maintained, accurate, and without discrepancy to allow for accurate reconciliation for Resident Identifier (RI) #400. In May 2024 Licensed Practical Nurse (LPN) #4 signed controlled medication (Hydrocodone-Acetaminophen) for Resident Identifier (RI) #400 without documenting the administration of the medication on RI #400's Electronic Medication Administration Record (EMAR) 35 times. This deficient practice had the potential to affect RI #400 one of three sampled residents. Findings include: A facility policy titled CONTROLLED MEDICATIONS ADMINISTRATION last revised 08/2016 documented the following: . POLICY: . as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. PROCEDURE: . 6. When administering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to accommodate the needs for one (1) (Resident Identifier [RI]#63) of 20 sampled residents, by providing a wheelchair appropriate for RI #63 to self-propel throughout the facility at will. Findings include: Review of the face sheet in the medical record for RI #63 revealed an original admission date of 10/23/17 with a readmission date of 1/3/2020 and diagnoses to include Diabetes, Hypothyroidism as well as other diagnoses. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 3/10/21 noted the Function Status in Section G revealed RI #63 required extensive assistance of one (1) person with transfers, and walking in room, requiring total dependence of one (1) person with locomotion on and off the unit and in Section G as having no impairment with range of motion to all extremities. The assessment identified RI #63 as requiring assistance from staff to stabilize when transferring and ambulating. This assessment was coded for the use of a wheelchair as a mobility device. Review of the Care Plan for RI…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-04-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of facility policy and review of the facility's Facility Reported Incident (FRI) investigation (AL00041339), the facility failed to ensure one (1) of 24 sampled residents (Resident Identifier [RI] #80) was free from abuse. Findings include: Review of the facility's policy titled Abuse Prevention, undated, revealed verbal abuse was defined as the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or withing their hearing distance, regardless of their age, ability to comprehend, or disability. Protection: 1. Any allegation of abuse or neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the residents. 2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2019-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and review of facility policies titled, Food Storage (Dry, Refrigerated, and Frozen), and Labeling and Dating Foods (Date Marking), the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler; 2. foods stored in the walk-in cooler were labeled with an open and/or use by date; and 3. dented cans were stored separately from other stock. These failures had the potential to affect 111 of 111 residents who received meals from the kitchen. Findings Include: 1) The facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), with a date of 2016 Edition, included, 1. c. Discard food that has passed the expiration date. On 03/10/19 at 10:11 AM, the surveyor observed food items in the walk-in cooler. There were two rolls of ground beef with a received by date of 02/20/19 and a discard date of 03/07/19 on both rolls. On 03/12/19 at 05:46 PM, the surveyor conducted an interview with Employee Identifier (EI) #5, the Dietician. The surveyor asked EI #5, what does a use by date of 03/07/19 mean. EI #5 stated, means we have to use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility policies titled Linens and MEDICATION STORAGE, the facility failed to ensure Employee Identifier (EI) # 6, Laundry Aide, did not allow clean linen to touch her uniform. The facility further failed to ensure personal food items were not stored in the medication refrigerator. This affected one employee observed performing laundry tasks on 3/13/19 and one of two medication refrigerators observed. Findings Include: 1) A review of a document titled Linens, dated 7/22/18, revealed the following: . Clean Linens must be protected from dust and soil until used .Keep linens away from personal clothing . On 3/13/19 at 10:05 AM the surveyor observed the laundry area of the facility. At 10:09 AM the surveyor observed EI # 6 folding sheets/towels and removing wet laundry from the washing machine and placing it in the dryer. The surveyor observed sheets/towels and wet laundry touching the top of EI # 6's uniform. On 3/13/19 at 10:43 AM an interview was conducted with EI # 6. EI # 6 was asked if she used personal protective equipment (PPE) when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-05-13 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, interview, and review of the Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from October 1, 2023 - December 31, 2023, to Centers for Medicare & Medicaid Services (CMS). This affected one quarter of data reviewed during the survey. Findings include: The PBJ report generated for the quarter of 10/01/2023 through 12/31/2023 documented .One star staffing Rating Triggered, and Excessively Low weekend Staffing Triggered . On 05/09/2024 at 4:06 PM, during an interview the the facility Executive Director/Administrator, she said, the human resources staff transmits the information pulled from the staff finger prints as they clock in, to the support office then the support office submits to CMS. She said, the report indicated low staff due to ancillary staff possibly not scanning if they worked as a Certified Nursing Assistant. She said, the one star indicated the facility could use more staff, however they had enough staffing to meet the needs for residents, but it did not pick up when the staff scanned in.
- No harm found · C2019-03-13 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to ensure the Nurse Staffing Information was posted daily. On 3/10/2018 during the initial tour, the Nurse Staffing Information was posted for 03/08/2019. This was observed on one of four days of the survey and had the potential to effect all residents, staff and visitors in the facility. Findings include: On 3/10/2019 at 10:19 a.m., during the initial tour, the surveyor observed the nurse staffing information was posted for 03/08/2019. On 3/12/19 at 3:01 p.m., an interview was conducted with Employee Identifier (EI) #1, Administrator. EI #1 was asked who was responsible for posting the nurse staffing information during the morning of the weekend of 3/10/2019. EI #1 stated it was EI # 3, Activity Director. EI #1 was asked if the facility had a policy on posting nurse staffing information. EI #1 stated the facility used the Centers for Medicare and Medicaid Services guidelines on how the nursing staffing should be posted daily. On 3/12/19 at 3:05 p.m., an interview was conducted with EI #3, Activity Director. EI #3 was asked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$24,834 in federal fines across 5 penalties. 1 Medicare payment denial on record.
- $4,017 — penalty dated 2024-05-13
- $4,017 — penalty dated 2024-05-13
- $5,600 — penalty dated 2024-05-13
- $5,600 — penalty dated 2024-05-13
- $5,600 — penalty dated 2024-05-13
- Medicare payment denial — starting 2024-06-12 for 54 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Alabama Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 015134. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.