Cycle 1
Health 2021-12-16 · Fire 2021-12-16
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Birmingham, AL
Galleria Woods Skilled Nursing Facility
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3850 Galleria Woods Drive, Birmingham, AL
(205) 985-7537
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
26
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
2007-02-16
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing
LPN hours / resident day
0.96
Licensed practical nurse staffing
Aide hours / resident day
2.47
Nurse aide staffing
Weekend hours
4.07
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
64%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.3%
7.4 pts better
|
93.4%
5.3 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 | 5.1% |
3.4%
1.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
1.3%
4 pts worse
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.3%
3.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
24.9%
14 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
22.8%
11.9 pts better
|
16.7%
5.8 pts better
|
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 | 11.4% |
14.8%
3.4 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
13.4%
5.9 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.3%
0.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
13.5%
14.6 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.7%
4.6 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
84.3%
0.7 pts worse
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
11.5%
4.4 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.1%
0.8 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
80.3%
6.9 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
24.5%
2.2 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-11 · Fire 2019-04-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-05-17 · Fire 2018-05-17
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-12-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-01-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2021-12-16
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 2022-01-12
F · Potential for more than minimal harm
2021-12-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-16
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 2022-01-12
D · Potential for more than minimal harm
2021-12-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-01-12
F · Potential for more than minimal harm
2019-04-11
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 2019-05-03
D · Potential for more than minimal harm
2019-04-11
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 2019-05-03
D · Potential for more than minimal harm
2019-04-11
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 2019-05-03
F · Potential for more than minimal harm
2018-05-17
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 2018-06-06
D · Potential for more than minimal harm
2018-05-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-06-06
D · Potential for more than minimal harm
2018-05-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-06-06
Penalties and ownership
What sits behind the stars
Ownership
Arc Galleria Woods Inc
5% Or Greater Security Interest · Organization
Ccrc Opco Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Ccrc Propco Ventures, LLC
5% Or Greater Direct Ownership Interest · Organization
Gilstrap, Jody
Operational/Managerial Control · Individual
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Sullivan, Lynda
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 2-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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Birmingham, AL
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Aspire Physical Recovery Center At Hoover, LLC
Hoover, AL
1-star overall rating with 1-star inspections with $15,593 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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