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

Staffing

Hours and turnover

RN hours / resident day

0.76

Registered nurse staffing

LPN hours / resident day

0.82

Licensed practical nurse staffing

Aide hours / resident day

2.48

Nurse aide staffing

Weekend hours

3.59

Weekend nurse staffing

RN turnover

25%

Annual RN turnover

Total nurse turnover

51%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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