Cycle 1
Health 2025-06-03 · Fire 2025-06-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Memphis, TN
Kirby Pines Manor
5-star overall rating with 5-star inspections with 2 recent health deficiencies
3535 Kirby Parkway, Memphis, TN
(901) 365-3665
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
6
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-03-07
CMS approved date
Coverage
Medicare
Participation flags
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
2.77
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
4.06
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.42
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
8.25
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
6.83
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
8.93
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
3.95
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.29
CMS adjusted RN staffing hours
Adjusted total hours
6.82
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
25%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
386
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0229
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.85
Baseline 18.77% · Performance 17.79% · Measure score 7.85 · Achievement 7.85 · Improvement 5.12
Healthcare-associated infections
4.86
Baseline 6.87% · Performance 6.38% · Measure score 4.86 · Achievement 4.86 · Improvement 2.12
Total nurse turnover
8.59
Baseline 51.85% · Performance 28.57% · Measure score 8.59 · Achievement 8.59 · Improvement 8.12
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 5.88% · Lower 95% interval 7.26% |
| Discharge to community | 53.67% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 49% · Lower 95% interval 45.24% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.96% |
95.27%
2.7 pts better
|
Numerator 48 · Denominator 49 |
| Falls with major injury | 4.08% |
0.77%
3.3 pts worse
|
Numerator 2 · Denominator 49 |
| Discharge self-care score | 48.65% |
53.69%
5 pts worse
|
Numerator 18 · Denominator 37 |
| Discharge mobility score | 51.35% |
50.94%
0.4 pts better
|
Numerator 19 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.38% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 3.51% · Lower 95% interval 3.32% |
| Staff COVID-19 vaccination coverage | 3.23% |
8.2%
5 pts worse
|
Numerator 3 · Denominator 93 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 93 · Denominator 93 |
| Discharge function score | 67.57% |
56.45%
11.1 pts better
|
Numerator 25 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 92.31% |
96.28%
4 pts worse
|
Numerator 24 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 35.71% |
25.2%
10.5 pts better
|
Numerator 10 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.6%
20.4 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 | 0.0% |
11.2%
11.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.6%
1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.8% · Q4 4.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.7% |
22.2%
9.5 pts better
|
23.9%
11.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 10.2% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-11-09 · Fire 2021-11-09
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-04-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-02
D · Potential for more than minimal harm
2024-04-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-04-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-06-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-06
Penalties and ownership
What sits behind the stars
Ownership
Herzke, Rudolf
Corporate Director · Individual
Herzke, Rudolf
W-2 Managing Employee · Individual
Myers, Constance
W-2 Managing Employee · Individual
Psalms, Inc
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
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Quince Nursing And Rehabilitation Center, LLC
Memphis, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $71,822 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare Of Primacy
Memphis, TN
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Waters Of Memphis A Rehabilitation & Nursing Ctr
Memphis, TN
2-star overall rating with 2-star inspections with $5,293 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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