Cycle 1
Health 2022-05-05 · Fire 2022-05-05
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pell City, AL
Village At Cook Springs Skilled Nursing Facility
1-star overall rating with 1-star inspections with 3 fire-safety deficiencies in the latest cycle
415 Cook Springs, Pell City, AL
(205) 338-2221
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
129
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Noland Health
Operator or chain grouping
Approved since
1977-12-01
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
0.54
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.70
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
3.95
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
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
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,755
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.76
Baseline 18.91% · Performance 20.15% · Measure score 2.76 · Achievement 2.76 · Improvement 0
Healthcare-associated infections
0
Baseline 5.77% · Performance 7.80% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.93
Baseline 63.64% · Performance 55.78% · Measure score 1.93 · Achievement 1.93 · Improvement 1.53
Adjusted total nurse staffing
4.36
Baseline 3.78 hours · Performance 4.32 hours · Measure score 4.36 · Achievement 4.36 · Improvement 2.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 10.71% · Lower 95% interval 7.98% |
| Discharge to community | 50.86% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 46.38% · Lower 95% interval 38.16% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 51.02% |
53.69%
2.7 pts worse
|
Numerator 25 · Denominator 49 |
| Discharge mobility score | 36.73% |
50.94%
14.2 pts worse
|
Numerator 18 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 6.56% |
2.29%
4.3 pts worse
|
Numerator 4 · Denominator 61 · Adjusted rate 7.67% |
| Healthcare-associated infections requiring hospitalization | 7.8% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 0.41% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 245 |
| Staff flu vaccination coverage | 97.9% |
42%
55.9 pts better
|
Numerator 280 · Denominator 286 |
| Discharge function score | 38.78% |
56.45%
17.7 pts worse
|
Numerator 19 · Denominator 49 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 4 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.3%
8.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.8% |
3.4%
0.4 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.9% · Q3 1.8% · Q4 2.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
1.3%
0.2 pts worse
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 1.3% · Q4 2.6% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.3%
1.5 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 8.8% · Q4 3.6% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.1% |
24.9%
9.2 pts worse
|
19.6%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 31.0% · Q3 37.4% · Q4 38.4% · 4Q avg 34.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.5% |
22.8%
4.7 pts worse
|
16.7%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 27.4% · Q3 24.4% · Q4 26.7% · 4Q avg 27.5% · 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 | 11.9% |
14.8%
2.9 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 12.6% · Q3 13.9% · Q4 10.3% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.3% |
13.4%
1.1 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 14.9% · Q3 11.8% · Q4 11.4% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
1.3%
1.2 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.3% · Q3 2.3% · Q4 0.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.4% |
2.6%
2.8 pts worse
|
1.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.8% · Q3 2.7% · Q4 5.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.9% |
13.5%
3.6 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 13.2% · Q3 7.6% · Q4 11.0% · 4Q avg 9.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.7%
1.6 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.6% · Q3 5.9% · Q4 2.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.5%
0.4 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.9% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
2.1%
About the same
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 1.5% · Q3 0.0% · Q4 1.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
80.3%
15.4 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
24.5%
2.9 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 25.4% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-28 · Fire 2019-07-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 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
2022-05-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-05-13
D · Potential for more than minimal harm
2022-05-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-27
E · Potential for more than minimal harm
2019-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-15
E · Potential for more than minimal harm
2019-07-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-15
E · Potential for more than minimal harm
2019-07-28
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 2019-08-15
E · Potential for more than minimal harm
2019-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-08-15
E · Potential for more than minimal harm
2019-07-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
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 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-15
D · Potential for more than minimal harm
2018-08-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-09-25
D · Potential for more than minimal harm
2018-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-09-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-12-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-24
J · Immediate jeopardy
2019-07-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-08-19
J · Immediate jeopardy
2019-07-28
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 2019-08-19
J · Immediate jeopardy
2019-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-08-19
D · Potential for more than minimal harm
2019-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-21
F · Potential for more than minimal harm
2018-08-16
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 2018-09-20
D · Potential for more than minimal harm
2018-08-16
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 2018-09-20
D · Potential for more than minimal harm
2018-08-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-09-20
D · Potential for more than minimal harm
2018-08-16
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 2018-09-20
D · Potential for more than minimal harm
2018-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-20
Penalties and ownership
What sits behind the stars
Ownership
Noland Health Services, Inc
5% Or Greater Direct Ownership Interest · Organization
Adamson, Michele
Corporate Director · Individual
Blackwell, Crystal
Operational/Managerial Control · Individual
Britton, Isaac
Corporate Director · Individual
Estep, Barbara
Operational/Managerial Control · Individual
Estep, Barbara
Corporate Director · Individual
Goff, Robert
Corporate Director · Individual
Hall, Matthew
Operational/Managerial Control · Individual
Kenwright, Karen
Operational/Managerial Control · Individual
Nelson, Debra
Corporate Director · Individual
Noland Health Services, Inc
Operational/Managerial Control · Organization
Pickell, Randolph
Operational/Managerial Control · Individual
Renda, Nicholas
Operational/Managerial Control · Individual
Renda, Nicholas
Corporate Director · Individual
Smith, George
Corporate Director · Individual
Smothers, Kathy
Operational/Managerial Control · Individual
Urban, Kelley
Operational/Managerial Control · Individual
Waggoner, James
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Diversicare Of Pell City
Pell City, AL
2-star overall rating with 2-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Meadowview Nursing Center
Pell City, AL
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cavalier Healthcare Of Trussville
Trussville, AL
2-star overall rating with 3-star inspections with $46,797 in total fines with 2 recent health deficiencies
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