Cycle 1
Health 2022-12-14 · Fire 2022-12-14
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Birmingham, AL
Cherry Hill Rehabilitation & Healthcare Center
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1250 Jeff Germany Parkway, Birmingham, AL
(205) 796-0214
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ball Healthcare Services
Operator or chain grouping
Approved since
2001-07-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 3 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
0.45
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.03
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,554
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.28
Baseline 19.78% · Performance 18.52% · Measure score 6.28 · Achievement 6.28 · Improvement 4.08
Healthcare-associated infections
6.72
Baseline 7.78% · Performance 5.83% · Measure score 6.72 · Achievement 6.72 · Improvement 6.51
Total nurse turnover
0
Performance 70.59% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.90 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 3.33% · Lower 95% interval 6.04% |
| Discharge to community | 36.16% |
50.57%
14.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 22.86% · Lower 95% interval 21.97% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 71.88% |
95.27%
23.4 pts worse
|
Numerator 23 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 13 · Denominator 23 |
| Discharge mobility score | 52.17% |
50.94%
1.2 pts better
|
Numerator 12 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 9.38% |
2.29%
7.1 pts worse
|
Numerator 3 · Denominator 32 · Adjusted rate 10.6% |
| Healthcare-associated infections requiring hospitalization | 5.83% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 0% · Lower 95% interval 2.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 104 |
| Discharge function score | 65.22% |
56.45%
8.8 pts better
|
Numerator 15 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.8 · 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 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.7% |
91.3%
9.6 pts worse
|
93.4%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 80.0% · Q3 73.7% · Q4 87.2% · 4Q avg 81.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.9% |
94.8%
10.9 pts worse
|
95.5%
11.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 1.0% · Q4 1.1% · 4Q avg 1.3% · 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 | 9.5% |
5.3%
4.2 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 12.5% · Q3 6.7% · Q4 7.1% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
24.9%
2.7 pts better
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 24.5% · Q3 22.3% · Q4 17.2% · 4Q avg 22.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
22.8%
2.9 pts better
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 20.8% · Q3 18.6% · Q4 23.9% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.6%
0.3 pts better
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
14.8%
0.8 pts worse
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 13.7% · Q3 13.0% · Q4 8.5% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
13.4%
1.2 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 10.5% · Q3 14.6% · Q4 6.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.3%
1.8 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 2.7% · Q4 4.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.9% · Q3 1.1% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.0% |
13.5%
7.5 pts better
|
19.8%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 2.2% · Q3 1.1% · Q4 10.7% · 4Q avg 6.0% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.7%
0.9 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.9% · Q3 2.5% · Q4 4.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.5% |
84.3%
44.8 pts worse
|
81.7%
42.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.5% · Q2 17.0% · Q3 21.1% · Q4 45.0% · 4Q avg 39.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
11.5%
9.1 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 23.1% · Expected 12.5% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 10.5% |
80.3%
69.8 pts worse
|
79.7%
69.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 10.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
24.5%
1.4 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 26.9% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-12 · Fire 2019-12-12
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-04-04 · Fire 2019-04-04
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-12-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-01-25
F · Potential for more than minimal harm
2022-12-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-25
E · Potential for more than minimal harm
2022-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-25
E · Potential for more than minimal harm
2022-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-25
E · Potential for more than minimal harm
2022-12-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-25
D · Potential for more than minimal harm
2022-12-14
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 2023-01-25
D · Potential for more than minimal harm
2019-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-17
D · Potential for more than minimal harm
2019-04-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-05-14
D · Potential for more than minimal harm
2019-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-05-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-12-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-14
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 2023-01-18
D · Potential for more than minimal harm
2022-12-14
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-14
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 2023-01-18
D · Potential for more than minimal harm
2022-12-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-18
E · Potential for more than minimal harm
2019-12-12
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 2020-01-21
Penalties and ownership
What sits behind the stars
Ownership
Ball, Clarence
5% Or Greater Direct Ownership Interest · Individual
Ball Healthcare Service, Inc
Operational/Managerial Control · Organization
Ball, Clarence
Corporate Director · Individual
Carter, Jacqueline
W-2 Managing Employee · Individual
Hall, Matthew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Birmingham Nursing And Rehabilitation Ctr LLC
Birmingham, AL
1-star overall rating with 1-star inspections with abuse icon flag with $111,811 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Oak Knoll Health And Rehabilitation, LLC
Birmingham, AL
2-star overall rating with 1-star inspections with $22,340 in total fines with 6 recent health deficiencies
#3
Northway Health And Rehabilitation, LLC
Birmingham, AL
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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