Cycle 1
Health 2023-03-16 · Fire 2023-03-16
3 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Birmingham, AL
East Glen
2-star overall rating with 2-star inspections with $14,521 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
53 Medical Park Drive East, Birmingham, AL
(205) 833-1777
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Noland Health
Operator or chain grouping
Approved since
1985-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,566
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.24% · Performance 24.15% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.86
Baseline 5.23% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Total nurse turnover
0.59
Baseline 63.22% · Performance 61.26% · Measure score 0.59 · Achievement 0.59 · Improvement 0.01
Adjusted total nurse staffing
4.05
Baseline 3.91 hours · Performance 4.23 hours · Measure score 4.05 · Achievement 4.05 · Improvement 1.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 7.92% · Lower 95% interval 7.08% |
| Discharge to community | 64.11% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 92 · Observed rate 59.78% · Lower 95% interval 54.99% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 40 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 13 · Denominator 27 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 18 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 7.14% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 91.89% |
42%
49.9 pts better
|
Numerator 136 · Denominator 148 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 17 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.3%
8.1 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.4%
0.9 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.7% · Q3 2.5% · Q4 1.3% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
1.3%
3.4 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 10.6% · Q4 4.9% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
5.3%
4.9 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 15.4% · Q3 7.5% · Q4 7.7% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
24.9%
1 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.7% · Q3 28.4% · Q4 26.2% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
22.8%
8.4 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.0% · Q3 13.8% · Q4 11.3% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.8% |
14.8%
3 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 19.2% · Q4 0.0% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
13.4%
4.7 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 8.3% · Q3 9.8% · Q4 3.4% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.3%
1.2 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.3% · Q3 3.1% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.6%
0.1 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 3.8% · Q4 3.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
13.5%
1.2 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 15.4% · Q3 11.4% · Q4 9.9% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.7%
2 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.0% · Q3 4.2% · Q4 5.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
84.3%
15 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
11.5%
2.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.1%
0.3 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 1.9% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
80.3%
17.6 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
24.5%
6.9 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 31.1% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-08 · Fire 2019-11-08
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-11-01 · Fire 2018-11-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-26
E · Potential for more than minimal harm
2019-11-08
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-11-08
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-11-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-11-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-06
D · Potential for more than minimal harm
2019-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-06
F · Potential for more than minimal harm
2018-11-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-11-30
Inspection history
Recent health citations
J · Immediate jeopardy
2023-06-10
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-03-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-20
F · Potential for more than minimal harm
2019-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-11-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-11-08
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-11-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-13
Penalties and ownership
What sits behind the stars
$14,521
2023-06-10
Fine
Fine · fine $14,521
Fine
Ownership
Noland Health Services, Inc
5% Or Greater Direct Ownership Interest · Organization
Adamson, Michele
Corporate Director · Individual
Ascension Health Alliance
5% Or Greater Indirect Ownership Interest · Organization
Blackwell, Crystal
Operational/Managerial Control · Individual
Britton, Isaac
Corporate Director · Individual
Estep, Barbara
Operational/Managerial Control · Individual
Estep, Barbara
Corporate Director · Individual
Goff, Robert
Corporate Director · Individual
Hall, Matthew
Operational/Managerial Control · Individual
Howard, Stephanie
Operational/Managerial Control · Individual
Kenwright, Karen
Operational/Managerial Control · Individual
Nelson, Debra
Corporate Director · Individual
Noland Health Services, Inc
Operational/Managerial Control · Organization
Polk, Yolonda
Operational/Managerial Control · Individual
Renda, Nicholas
Operational/Managerial Control · Individual
Renda, Nicholas
Corporate Director · Individual
Smith, George
Corporate Director · Individual
Smothers, Kathy
Operational/Managerial Control · Individual
Urban, Kelley
Operational/Managerial Control · Individual
Waggoner, James
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Birmingham Nursing And Rehabilitation Center East
Birmingham, AL
2-star overall rating with 1-star inspections with $24,834 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cavalier Healthcare Of Trussville
Trussville, AL
2-star overall rating with 3-star inspections with $46,797 in total fines with 2 recent health deficiencies
#3
Eastview Rehabilitation & Healthcare Center
Birmingham, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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