Willowbrooke Ct Skilled Care Ctr Westminster Vlg
500 Spanish Fort Blvd, Spanish Fort, AL 36527 · Non profit - Corporation · 60 certified beds · (251) 626-7007 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- its payroll-based staffing score sits well above its independent inspection score
- its last standard health inspection was over 5 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 improved from 2 to 5 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 with a catheter left in their bladder | 0.0% | 1.0% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.4% | 2.0% | better |
| 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 | 0.0% | 3.3% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents with pressure ulcers | 9.4% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.8% | 12.8% | 21.2% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 80.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 30.9% | 24.8% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.3% | 11.3% | 12.0% | 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.
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.
52.1% 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 74 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 1.66 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 52.1%CMS range 42.9–62.0 | 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 | 12.4%CMS range 9.2–17.8 | 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 | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.7–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 60 beds and averages 9.8 residents a day — about 16% occupied, or roughly 50 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.40 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 is at or above 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 4.29 hrs/resident/day on weekends vs 4.57 on weekdays — 6% thinner on weekends. RN hours go from 1.40 to 1.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 unchanged from the previous inspection. 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 5 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.
10 citations, most serious first — scroll within the box to see all.
- Potential for harm · Fcited before2021-04-08 · 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 observation, interview, record review, and review of the facility policy, the facility failed to store, prepare, and serve food under sanitary conditions for 38 of 38 residents who received food prepared in the kitchen. Observations on 4/6/21 in the kitchen revealed uncovered, unrefrigerated, and unlabeled food, no dates on prepared food, storage containers containing debris and unclean workstations. Findings include: An initial tour of the kitchen was conducted on 4/6/21 at 9:21 am. Upon inspection of the sandwich prep refrigerator located by the steamtable, the following items were observed: Sliced lemons covered with no date, sliced red onion covered with no date, a green pepper cut open sitting on top of other food items unwrapped, yellow sliced cheese wrapped with no date, white sliced cheese wrapped with no date, a small container of chicken salad with no date of preparation or expiration, and a small container of egg salad with no date of preparation or expiration. An inspection of the reach-in refrigerator located by the toaster, the following items were observed:…
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 · Fcited before2019-02-14 · 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 a facility policy titled PERSONAL APPEARANCE STANDARDS, the facility failed to ensure: 1) opened and undated foods were not observed in the freezer; 2) the ice machine was not found with a black residue inside the ice storage compartment; and 3) hair was not uncovered on staff while working in the kitchen. This had the potential to affect all forty-two residents receiving meals from the kitchen. Findings Include: 1) On 2/12/2019 at 7:56 AM, during the tour of the kitchen, a brown paper bag of hashbrowns was observed opened and exposed with no date. A brown paper bag of tater tots was also observed open and exposed to air, without a date. On 2/14/2019 at 1:35 PM, Employee Identifier (EI) 3, the Director of Culinary Services, was interviewed. When asked what the facility's policy was regarding opened and undated food items in the freezer, EI #3 said the items should be sealed and dated, and if there was no date, the item should be discarded. He said if items were open and exposed or undated, there was a potential for contamination. 2)…
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 · Fcited before2018-03-01 · 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 record reviews, including the facility's policy titled, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, and the Food and Drug Administration Food Code, the facility failed to ensure: 1) a container of chopped fruits, a tray of hamburger patties, and a container of green beans had an expiration date on them; 2) a tray of fruit cups and bowls of bread pudding were covered and dated; and 3) a pan of brownies in the cooler was covered. This affected 40 of 40 residents who receive a meal from the kitchen. Findings Include: A review of the Food and Drug Administration Food Code 2013, Chapter 3 Food Storage page 76, revealed the following: .3-305-11 Food Storage : (A) Except as specified in (B) and (C) of this section, Food shall be protected from contamination by storing the FOOD: .(2) Where it is not exposed to splash, dust, or other contamination; and A review of a facility policy, SUBJECT: OPERATIONAL STANDARDS REFRIGERATOR, with a revision date of 2/17, revealed: POLICY: To strive to ensure all refrigerators (kitchens, pantries and country kitchens)…
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 · E2018-03-01 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and a review of a facility policy titled, Abuse, Neglect . the facility failed to ensure the Abuse Policy indicated the reporting time of alleged abuse within two hours of being reported by staff to administration. This affected RI #4, #5, and #15, three of three residents named in allegations of abuse reviewed and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator, or designee will take the following actions: A. Notify the appropriate state agency…
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 · E2018-03-01 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, review of abuse allegation files, and the review of a facility policy titled, Abuse, Neglect ., the facility failed to ensure three allegations of abuse were reported to the State Agency within two hours of being reported by staff to the administration. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents named in allegations of abuse the facility reported to the State Agency and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the reporting of concerns/problems and protects residents; preserving their dignity and quality of life . Reporting: . 4. The executive director, administrator,…
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 · E2018-03-01 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, the Abuse Policy, and Alleged Abuse Reports submitted to the State Agency from 11/17 to 02/18, the facility failed to ensure the Administrator, who was responsible for the overall management of the facility, and the Director of Nursing, who was responsible for the overall management of the Nursing Department, ensured the facility reported alleged abuse of three residents within the two hour required time period. This affected RI (Resident Identifier) #4, #5, and RI #15, three of three residents named in alleged abuse incidents from 11/17 through 2/18, and had the potential to affect all residents involved in abuse allegations residing at the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . PURPOSE: The purpose of this policy is to promote the maintenance of a living environment that fosters the…
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 · E2018-03-01 · tag F0837 — patternEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review of the policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, and interviews, the facility failed to ensure the Governing Body maintained a process that ensured the abuse policy contained the correct time frame for reporting alleged abuse. This was evidenced by the Abuse Policy not indicating the required two hour reporting period for all alleged abuse. This affected RI (Resident Identifier) #4, #5, and #15, three of three residents with facility reported alleged abuse allegations and had the potential to affect all residents involved in abuse allegations who reside in the facility. Findings Include: A review of the facility's policy titled, SUBJECT: ABUSE, NEGLECT, INVOLUNTARY SECLUSION, EXPLOITATION, AND MISAPPROPRIATION OF PROPERTY PREVENTION, with a revision date of 11/17, revealed: POLICY: To strive to ensure residents will be safeguarded and protected from any form of abuse, . Reporting: . 1. Anyone who finds injury of unknown origin must immediately report the incident. 2. Anyone who…
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 · E2018-03-01 · tag F0865 — failed to run a quality-improvement (QAPI) program — patternHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and a review of the facility policy and procedure titled, Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program, the facility failed to ensure the QAPI committee reviewed and identified the required regulatory change for reporting allegations of abuse within two hours to the State Agency. This affected three of three reported allegations of abuse submitted to the Alabama Department of Public Health and had the potential to affect all residents involved in abuse allegations residing in the facility. Findings Include: A review of a facility policy titled,Quality Assurance, Performance Improvement and Compliance Manual, revealed: Subject: Quality Assurance, Performance Improvement (QAPI) and Compliance Program Purpose: The purpose of . is to take a proactive approach to strive to continually improve the quality of life, care and services for our residents, caregivers, and other partners legally, morally and ethically. To do this, employees will participate in ongoing QAPI and compliance efforts through the continuous evaluation of care…
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 · D2018-03-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 and a review of POTTER/[NAME], FUNDAMENTALS OF NURSING the facility failed to ensure the documents of an abuse investigation were complete and correct as evidenced by forms with no dates, times, and incorrect dates. This was revealed in one of three allegations of abuse reported to the State Agency and affected RI (Resident Identifier) #4, one of three reports reviewed for alleged abuse. Findings Include: A review of POTTER/[NAME], FUNDAMENTALS OF NURSING, 9TH EDITION, Chapter twenty-six, Documentation, page 361, revealed: .Guidelines for Quality Documentation, . High quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete . Accurate . you need to date and time all entries in medical records and there needs to be a method to identify the author of all entries. A review of the allegation of abuse report for RI #4 revealed the following: A facility form titled, Incident…
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 · C2018-03-01 · 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, interview, and review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, the facility failed to ensure staff posting was not completed on all shifts prior to the shift worked. This was observed on two of four survey days and had the potential to affect all residents in the facility. Findings Include: A review of a facility policy titled, POSTING OF NURSING STAFF INFORMATION, with a revision date of 7/16, revealed: POLICY: To strive to post staffing information as scheduled for a twenty four (24) hour period. PROCEDURE: .2. The information should be posted at the beginning of each shift, with any needed changes made as soon as possible. On 2/27/18 at 12:50 P.M., the DAILY NURSE STAFFING FORM was observed in a plastic stand at the nurses station with the total hours of all three shifts filled out completely. Included on the staffing form was the number of RNs (Registered Nurse), LPNs (Licensed Practical Nurse), and CNAs (Certified Nursing Assistant) for night shift, day shift, and evening shift with scheduled hours worked included. On 2/28/18 at…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- 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
No federal fines in the current CMS record.
Part of a chain
This home belongs to ACTS RETIREMENT-LIFE COMMUNITIES — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 4.4 | -1.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 26 homes this chain runs (chain average 4.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 02/01/2023 |
| ALLMOND, SUSAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2025 |
| BROD, KATHRYN | Individual | CORPORATE DIRECTOR | since 02/15/2024 |
| CALLAWAY, WARREN | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| CHAMBERLAIN, LINDA | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| CHRISTIANSEN, KAREN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| DETWEILER, HAROLD | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| ESTERHAI, JOHN | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| GERNER, ELRIC | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/01/2023 |
| GLYNN, JAMES | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| GRANT, GERALD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| GREER, JASON | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| KELLY, MICHAEL | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| LAMMERS, JOHN | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| LAWSON, DANIEL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2025 |
| MASHNER, MARVIN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/01/2023 |
| MIDDLEBROOKS, DANIEL | Individual | CORPORATE DIRECTOR | since 02/01/2023 |
| REICHARD, DAWN | Individual | CORPORATE DIRECTOR | since 06/01/2025 |
| AHERN, SUSAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| FOX, GLENN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| ACTS MANAGEMENT SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| ACTS RETIREMENT-LIFE COMMUNITIES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| VARDEN, KEVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| WEBB, GLORYANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| U.S. BANK | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | since 07/09/2025 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | since 02/03/2025 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | since 11/05/2024 |
CMS files one row per role, so the 47 rows in the source record cover these 27 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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.
This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 015381. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2021-04-08, 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.