Cycle 1
Health 2024-06-27 · Fire 2024-06-27
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Birmingham, AL
Brookdale University Park SNF (Al)
1-star overall rating with 1-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
501 University Park Drive, Birmingham, AL
(205) 870-0786
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2002-09-04
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 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
0.88
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.17
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,542
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.54
Baseline 21.09% · Performance 18.87% · Measure score 5.54 · Achievement 5.54 · Improvement 4.98
Healthcare-associated infections
3.47
Baseline 6.53% · Performance 6.80% · Measure score 3.47 · Achievement 3.47 · Improvement 0
Total nurse turnover
4.46
Baseline 80.21% · Performance 52.78% · Measure score 4.46 · Achievement 2.67 · Improvement 4.46
Adjusted total nurse staffing
2.34
Baseline 4.17 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 7.73% · Lower 95% interval 6.94% |
| Discharge to community | 58.79% |
50.57%
8.2 pts better
|
Better than the National Rate · Eligible stays 208 · Observed rate 54.33% · Lower 95% interval 51.06% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 89.36% |
95.27%
5.9 pts worse
|
Numerator 126 · Denominator 141 |
| Falls with major injury | 0.71% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 141 |
| Discharge self-care score | 57.28% |
53.69%
3.6 pts better
|
Numerator 59 · Denominator 103 |
| Discharge mobility score | 49.51% |
50.94%
1.4 pts worse
|
Numerator 51 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 6 · Denominator 141 · Adjusted rate 3.57% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 5.38% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 3.03% |
8.2%
5.2 pts worse
|
Numerator 3 · Denominator 99 |
| Staff flu vaccination coverage | 50.44% |
42%
8.4 pts better
|
Numerator 57 · Denominator 113 |
| Discharge function score | 60.19% |
56.45%
3.7 pts better
|
Numerator 62 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 95.18% |
96.28%
1.1 pts worse
|
Numerator 79 · Denominator 83 |
| Resident COVID-19 vaccinations up to date | 13.43% |
25.2%
11.8 pts worse
|
Numerator 9 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
91.3%
5.5 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.0% · Q3 96.7% · Q4 96.7% · 4Q avg 96.8% |
| 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 | 4.0% |
3.4%
0.6 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.1% · Q3 0.0% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.3%
1.3 pts better
|
11.4%
11.4 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 who lose too much weight | 5.1% |
5.3%
0.2 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
24.9%
1.7 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.9% |
22.8%
4.9 pts better
|
16.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · 4Q avg 17.9% · 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 · 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 | 12.8% |
14.8%
2 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
13.4%
8.1 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 3.4% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
13.5%
9.7 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 15.5% · Q3 23.7% · Q4 30.7% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.7%
0.4 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.3% · Q3 6.3% · Q4 4.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
84.3%
7 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 96.5% · Q3 91.6% · Q4 87.4% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
11.5%
About the same
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
2.1%
1.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.3% |
80.3%
12 pts better
|
79.7%
12.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
24.5%
2.9 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 20.0% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-05 · Fire 2019-12-05
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-11-20 · Fire 2018-11-20
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-06-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
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 2024-07-26
D · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-26
F · Potential for more than minimal harm
2019-12-05
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 2020-01-10
D · Potential for more than minimal harm
2019-12-05
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2020-01-10
D · Potential for more than minimal harm
2019-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-10
D · Potential for more than minimal harm
2019-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-10
F · Potential for more than minimal harm
2018-11-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-01-03
F · Potential for more than minimal harm
2018-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-01-03
F · Potential for more than minimal harm
2018-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-01-03
F · Potential for more than minimal harm
2018-11-20
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 2019-01-03
D · Potential for more than minimal harm
2018-11-20
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-01-03
D · Potential for more than minimal harm
2018-11-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-01-03
D · Potential for more than minimal harm
2018-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-23
F · Potential for more than minimal harm
2024-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-23
E · Potential for more than minimal harm
2024-06-27
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 2024-06-12
D · Potential for more than minimal harm
2024-06-27
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 2024-04-08
D · Potential for more than minimal harm
2024-06-27
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-06-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-12
F · Potential for more than minimal harm
2019-12-05
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 2020-01-08
E · Potential for more than minimal harm
2019-12-05
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 2020-01-08
D · Potential for more than minimal harm
2019-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-08
F · Potential for more than minimal harm
2018-11-20
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 2018-12-24
D · Potential for more than minimal harm
2018-11-20
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 2018-12-24
D · Potential for more than minimal harm
2018-11-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-24
D · Potential for more than minimal harm
2018-11-20
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 2018-12-24
D · Potential for more than minimal harm
2018-11-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-12-24
D · Potential for more than minimal harm
2018-11-20
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 2018-12-24
Penalties and ownership
What sits behind the stars
Ownership
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Al Balas, Alian
Operational/Managerial Control · Individual
Bornstein, Brandon
Operational/Managerial Control · Individual
Capital One Na
5% Or Greater Security Interest · Organization
Capital One Na
5% Or Greater Mortgage Interest · Organization
Gann, Patsy
Operational/Managerial Control · Individual
Kaestner, Henry
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Pippen, Princess
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
Stengle, Nikolas
Corporate Officer · Individual
White, Chadwick
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Elite Nursing And Rehabilitation Care Center
Birmingham, AL
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
#2
South Health And Rehabilitation, LLC
Birmingham, AL
1-star overall rating with 2-star inspections with $8,569 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Greenbriar At The Altamont Skilled Nursing Facilit
Birmingham, AL
3-star overall rating with 3-star inspections with 1 recent health deficiencies
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