Daphne, AL

Eastern Shore Rehabilitation And Health Center

3-star overall rating with 3-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

101 Villa Drive, Daphne, AL

(251) 621-4200

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

117

Certified beds

Average residents

98

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Noland Health

Operator or chain grouping

Approved since

1967-01-23

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

0.76

Registered nurse staffing · state 0.64 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

2.48

Nurse aide staffing · state 2.50 · national 2.35

Total nurse hours

4.06

All reported nurse hours · state 3.91 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.59

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.54

Weekend registered nurse coverage · state 0.36 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.87

CMS adjusted RN staffing hours

Adjusted total hours

4.64

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

25%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,611

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

Performance score

55.27

Composite VBP score used to determine payment impact.

Payment multiplier

1.0103

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.39

Baseline 26.82% · Performance 23.01% · Measure score 3.39 · Achievement 0 · Improvement 3.39

Healthcare-associated infections

8.63

Baseline 7.10% · Performance 5.26% · Measure score 8.63 · Achievement 8.63 · Improvement 8.26

Total nurse turnover

4.05

Baseline 57.69% · Performance 47.12% · Measure score 4.05 · Achievement 4.05 · Improvement 2.72

Adjusted total nurse staffing

6.04

Baseline 3.13 hours · Performance 4.80 hours · Measure score 6.04 · Achievement 6.04 · Improvement 5.78

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.79%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 365 · Observed rate 9.59% · Lower 95% interval 8.24%
Discharge to community	66.31%	50.57% 15.7 pts better	Better than the National Rate · Eligible stays 323 · Observed rate 65.33% · Lower 95% interval 61.89%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	99.58%	95.27% 4.3 pts better	Numerator 239 · Denominator 240
Falls with major injury	0.42%	0.77% 0.4 pts better	Numerator 1 · Denominator 240
Discharge self-care score	64.58%	53.69% 10.9 pts better	Numerator 124 · Denominator 192
Discharge mobility score	59.9%	50.94% 9 pts better	Numerator 115 · Denominator 192
Pressure ulcers or injuries, new or worsened	2.92%	2.29% 0.6 pts worse	Numerator 7 · Denominator 240 · Adjusted rate 3.8%
Healthcare-associated infections requiring hospitalization	5.26%	7.12% 1.9 pts better	No Different than the National Rate · Eligible stays 222 · Observed rate 2.7% · Lower 95% interval 3.13%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 112
Staff flu vaccination coverage	93.75%	42% 51.8 pts better	Numerator 105 · Denominator 112
Discharge function score	61.98%	56.45% 5.5 pts better	Numerator 119 · Denominator 192
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 45 · Denominator 45
Transfer of health information to patient	97.66%	96.28% 1.4 pts better	Numerator 167 · Denominator 171
Resident COVID-19 vaccinations up to date	10.16%	25.2% 15 pts worse	Numerator 13 · Denominator 128

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.9	2.0 0.1 pts better	1.9 About the same	Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.1	1.8 0.3 pts worse	1.8 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.4%	91.3% 6.1 pts better	93.4% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 97.3% · Q4 94.1% · 4Q avg 97.4%
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	4.7%	3.4% 1.3 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 6.8% · Q4 7.4% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.8%	1.3% 0.5 pts better	11.4% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.8% · 4Q avg 0.8%
Percentage of long-stay residents who lose too much weight	3.7%	5.3% 1.6 pts better	5.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.6% · Q3 7.1% · Q4 2.0% · 4Q avg 3.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	26.8%	24.9% 1.9 pts worse	19.6% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 26.8% · Q3 28.1% · Q4 26.9% · 4Q avg 26.8%
Percentage of long-stay residents who received an antipsychotic medication	26.1%	22.8% 3.3 pts worse	16.7% 9.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 29.3% · Q3 22.7% · Q4 17.5% · 4Q avg 26.1% · 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	14.9%	14.8% 0.1 pts worse	16.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 4.0% · Q3 17.1% · Q4 21.0% · 4Q avg 14.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.0%	13.4% 0.6 pts worse	14.9% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 16.7% · Q4 36.7% · 4Q avg 14.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.2%	1.3% 0.9 pts worse	1.0% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.9% · Q3 2.0% · Q4 1.7% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.6%	2.6% About the same	1.7% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 5.5% · Q4 3.0% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	7.6%	13.5% 5.9 pts better	19.8% 12.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.0% · Q3 7.9% · Q4 11.8% · 4Q avg 7.6%
Percentage of long-stay residents with pressure ulcers	6.5%	5.7% 0.8 pts worse	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.1% · Q3 7.2% · Q4 6.1% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.0%	84.3% 9.7 pts better	81.7% 12.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 95.5% · Q3 92.5% · Q4 90.4% · 4Q avg 94.0%
Percentage of short-stay residents who had an outpatient emergency department visit	6.7%	11.5% 4.8 pts better	12.0% 5.3 pts better	Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.2% · Expected 10.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	2.1% 0.7 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.6% · Q3 0.5% · Q4 2.5% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.8%	80.3% 16.5 pts better	79.7% 17.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.8%	24.5% 3.3 pts worse	23.9% 3.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 21.1% · Expected 18.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2021-03-26 · Fire 2021-03-26

3 health deficiencies

Top issue: Resident Rights (2 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2019-01-31 · Fire 2019-01-31

3 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2018-02-15 · Fire 2018-02-15

1 health deficiencies

Top issue: Resident Assessment and Care Planning (1 deficiency)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2021-03-26

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2021-04-30

E · Potential for more than minimal harm 2019-01-31

K904 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a properly installed medical gas master alarm panel.

Corrected 2019-03-14

D · Potential for more than minimal harm 2019-01-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-03-14

D · Potential for more than minimal harm 2019-01-31

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2019-03-14

C · Minimal harm 2018-02-15

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2018-03-09

C · Minimal harm 2018-02-15

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2018-03-09

Inspection history

Recent health citations

E · Potential for more than minimal harm 2021-03-26

F578 · Resident Rights Deficiencies

Health

Honor 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.

Corrected 2021-04-30

D · Potential for more than minimal harm 2021-03-26

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2021-04-30

D · Potential for more than minimal harm 2021-03-26

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2021-04-30

D · Potential for more than minimal harm 2019-01-31

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2019-03-07

D · Potential for more than minimal harm 2019-01-31

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-03-07

D · Potential for more than minimal harm 2019-01-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-03-07

D · Potential for more than minimal harm 2018-02-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2018-03-22

Penalties and ownership