Cycle 1
Health 2024-03-29 · Fire 2024-03-29
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
Elite Nursing And Rehabilitation Care Center
1-star overall rating with 1-star inspections with $6,682 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 Royal Tower Drive, Birmingham, AL
(205) 870-5666
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
124
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-11-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.41
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
0.70
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
74%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,215
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.18
Baseline 19.20% · Performance 20.42% · Measure score 2.18 · Achievement 2.18 · Improvement 0
Healthcare-associated infections
0
Baseline 9.20% · Performance 10.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 56.52% · Performance 62.02% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.19
Baseline 3.34 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 2.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 9.2% · Lower 95% interval 7.14% |
| Discharge to community | 37.23% |
50.57%
13.3 pts worse
|
Worse than the National Rate · Eligible stays 68 · Observed rate 27.94% · Lower 95% interval 25.31% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.25% |
95.27%
3 pts better
|
Numerator 56 · Denominator 57 |
| Falls with major injury | 1.75% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 57 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 20 · Denominator 32 |
| Discharge mobility score | 65.63% |
50.94%
14.7 pts better
|
Numerator 21 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 15.79% |
2.29%
13.5 pts worse
|
Numerator 9 · Denominator 57 · Adjusted rate 10.07% |
| Healthcare-associated infections requiring hospitalization | 10.32% |
7.12%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 16.18% · Lower 95% interval 6.54% |
| Staff COVID-19 vaccination coverage | 1.47% |
8.2%
6.7 pts worse
|
Numerator 3 · Denominator 204 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 329 |
| Discharge function score | 68.75% |
56.45%
12.3 pts better
|
Numerator 22 · Denominator 32 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 41.38% |
25.2%
16.2 pts better
|
Numerator 12 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
91.3%
6.9 pts worse
|
93.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.5% · Q2 78.2% · Q3 94.5% · Q4 96.6% · 4Q avg 84.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
94.8%
3.3 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| 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 1.6% · Q2 1.7% · Q3 3.1% · Q4 3.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
1.3%
1.1 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.3%
0.5 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.1% · Q3 2.6% · Q4 2.9% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
24.9%
0.2 pts worse
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 26.0% · Q3 22.6% · Q4 24.8% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.3% |
22.8%
9.5 pts worse
|
16.7%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 35.3% · Q3 31.6% · Q4 33.3% · 4Q avg 32.3% · 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 | 20.5% |
14.8%
5.7 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 15.1% · Q3 24.8% · Q4 18.9% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
13.4%
10.1 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 26.3% · Q3 22.4% · Q4 17.0% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
2.6%
2.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.0% |
13.5%
1.5 pts worse
|
19.8%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 16.3% · Q3 22.1% · Q4 10.4% · 4Q avg 15.0% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.7%
0.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.8% · Q3 4.3% · Q4 4.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
84.3%
34.3 pts worse
|
81.7%
31.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.0% · Q2 54.3% · Q3 46.9% · Q4 44.7% · 4Q avg 50.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
11.5%
3.8 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.8% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.1%
2.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.4% |
80.3%
39.9 pts worse
|
79.7%
39.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
24.5%
3.4 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 19.6% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-20 · Fire 2019-11-20
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-11-08 · Fire 2018-11-08
7 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-06
E · Potential for more than minimal harm
2024-03-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-29
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-06
E · Potential for more than minimal harm
2019-11-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2019-12-10
E · Potential for more than minimal harm
2019-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-11-20
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-11-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-09
D · Potential for more than minimal harm
2018-11-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2018-12-19
D · Potential for more than minimal harm
2018-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-19
D · Potential for more than minimal harm
2018-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-12-19
D · Potential for more than minimal harm
2018-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-12-19
D · Potential for more than minimal harm
2018-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-23
F · Potential for more than minimal harm
2024-08-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-08-13
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-03-29
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 2024-05-02
F · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-03-29
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-03-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-03-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-03-29
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 2024-05-02
D · Potential for more than minimal harm
2024-03-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-02
F · Potential for more than minimal harm
2019-11-20
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 2019-12-24
D · Potential for more than minimal harm
2019-11-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-24
E · Potential for more than minimal harm
2018-11-08
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 2018-12-12
E · Potential for more than minimal harm
2018-11-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-08
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 2018-12-12
D · Potential for more than minimal harm
2018-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-12
D · Potential for more than minimal harm
2018-11-08
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 2018-12-12
D · Potential for more than minimal harm
2018-11-08
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 2018-12-12
Penalties and ownership
What sits behind the stars
$6,682
2024-08-13
Fine
Fine · fine $6,682
Fine
Ownership
Kaplan, Yisroel
5% Or Greater Direct Ownership Interest · Individual
Bell, Tisha
W-2 Managing Employee · Individual
Kaplan, Yisroel
Operational/Managerial Control · Individual
Kaplan, Yisroel
Corporate Officer · Individual
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#2
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#3
Greenbriar At The Altamont Skilled Nursing Facilit
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3-star overall rating with 3-star inspections with 1 recent health deficiencies
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