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
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
1.09
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
5.55
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Performance 19.96% · Measure score 3.17 · Achievement 3.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.05% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.23
Baseline 44.12% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 0
Adjusted total nurse staffing
5.55
Baseline 5.09 hours · Performance 4.66 hours · Measure score 5.55 · Achievement 5.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.99% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 16.39% · Lower 95% interval 8.44% |
| Discharge to community | 60.69% |
50.57%
10.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 63.64% · Lower 95% interval 48.41% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 45 |
| Discharge self-care score | 52.94% |
53.69%
0.8 pts worse
|
Numerator 18 · Denominator 34 |
| Discharge mobility score | 47.06% |
50.94%
3.9 pts worse
|
Numerator 16 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 45 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 57 |
| Staff flu vaccination coverage | 3.08% |
42%
38.9 pts worse
|
Numerator 2 · Denominator 65 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 18 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
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 · Q2 100.0% · 4Q avg 98.7% |
| 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 | 5.1% |
3.4%
1.7 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 5.1% · Used in QM five-star |
| 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 · Q2 9.1% · 4Q avg 5.3% |
| 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 · 4Q avg 1.9% |
| 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 · 4Q avg 10.9% |
| 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 · 4Q avg 10.9% · 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 · Q2 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 11.4% · Used in QM five-star |
| 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 · 4Q avg 7.5% · Used in QM five-star |
| 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 · Q2 0.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q2 4.5% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q2 43.3% · 4Q avg 28.1% |
| 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 · Q2 0.0% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 96.4% · Q2 87.2% · Q3 76.9% · Q4 74.1% · 4Q avg 83.6% |
| 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 · Adjusted 7.1% · Observed 6.1% · Expected 9.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.4% · 4Q avg 1.3% · Used in QM five-star |
| 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 · 4Q avg 87.2% |
| 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 · Adjusted 26.7% · Observed 21.2% · Expected 18.9% · Used in QM five-star |
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
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#3
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