Cycle 1
Health 2021-10-07 · Fire 2021-10-07
1 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Birmingham, AL
Kirkwood By The River
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
3605 Ratliff Road, Birmingham, AL
(205) 956-2184
Overall
3 / 5
CMS overall stars
Health inspections
4 / 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
61
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-09-08
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
0.59
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.24
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.55
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,178
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 24.35% · Performance 22.33% · Measure score 2.25 · Achievement 0 · Improvement 2.25
Healthcare-associated infections
8.04
Baseline 9.63% · Performance 5.67% · Measure score 8.04 · Achievement 7.23 · Improvement 8.04
Total nurse turnover
2.89
Performance 51.85% · Measure score 2.89 · Achievement 2.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.05
Baseline 4.59 hours · Performance 4.52 hours · Measure score 5.05 · Achievement 5.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 6.61% · Lower 95% interval 6.85% |
| Discharge to community | 42.66% |
50.57%
7.9 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 37.6% · Lower 95% interval 36.59% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 75 · Denominator 76 |
| Falls with major injury | 2.63% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 76 |
| Discharge self-care score | 38.89% |
53.69%
14.8 pts worse
|
Numerator 21 · Denominator 54 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 12 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 1 · Denominator 76 · Adjusted rate 1.44% |
| Healthcare-associated infections requiring hospitalization | 5.67% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 89 · Observed rate 2.25% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 9.57% |
42%
32.4 pts worse
|
Numerator 9 · Denominator 94 |
| Discharge function score | 27.78% |
56.45%
28.7 pts worse
|
Numerator 15 · Denominator 54 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · 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 1.4 · 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 | 98.0% |
94.8%
3.2 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.4%
2.4 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 4.7% · Q4 5.7% · 4Q avg 5.8% · 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 | 8.7% |
5.3%
3.4 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 14.3% · Q3 3.8% · Q4 8.7% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.6% |
24.9%
0.7 pts worse
|
19.6%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 22.9% · Q3 33.3% · Q4 34.8% · 4Q avg 25.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.4% |
22.8%
17.6 pts worse
|
16.7%
23.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 50.0% · Q3 35.0% · 4Q avg 40.4% · 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 need for help with daily activities has increased | 30.1% |
13.4%
16.7 pts worse
|
14.9%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 50.0% · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.3%
0.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 4.8% · Q4 5.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
13.5%
0.2 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 16.3% · Q3 7.9% · Q4 3.1% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.7%
4.6 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 13.3% · Q3 10.3% · Q4 5.1% · 4Q avg 10.3% · 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 | 16.8% |
11.5%
5.3 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 14.5% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.1%
0.1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.2% · Q3 0.0% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
80.3%
18.1 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 55.0% |
24.5%
30.5 pts worse
|
23.9%
31.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 55.0% · Observed 42.0% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-03-28 · Fire 2019-03-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2018-03-22 · Fire 2018-03-22
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-10-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-11-08
E · Potential for more than minimal harm
2021-10-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-08
E · Potential for more than minimal harm
2021-10-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-11-08
E · Potential for more than minimal harm
2021-10-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-08
E · Potential for more than minimal harm
2021-10-07
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 2021-11-08
D · Potential for more than minimal harm
2021-10-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-08
D · Potential for more than minimal harm
2021-10-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-08
F · Potential for more than minimal harm
2019-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-05-07
F · Potential for more than minimal harm
2019-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-07
D · Potential for more than minimal harm
2018-03-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-04-04
D · Potential for more than minimal harm
2018-03-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-04-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2021-10-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-11
F · Potential for more than minimal harm
2019-03-28
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 2019-05-02
D · Potential for more than minimal harm
2019-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-02
D · Potential for more than minimal harm
2018-03-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-04-24
D · Potential for more than minimal harm
2018-03-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-04-24
D · Potential for more than minimal harm
2018-03-22
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2018-04-24
D · Potential for more than minimal harm
2018-03-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-04-24
D · Potential for more than minimal harm
2018-03-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-04-24
Penalties and ownership
What sits behind the stars
Ownership
Brunstad, Margaret
Corporate Officer · Individual
Burchfield, Jeffrey
Operational/Managerial Control · Individual
Carter, Chad
Corporate Officer · Individual
Higgins, John
Corporate Officer · Individual
Snow, James
Corporate Officer · Individual
Thomas, Adeeb
Operational/Managerial Control · Individual
Widman, William
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
East Glen
Birmingham, AL
2-star overall rating with 2-star inspections with $14,521 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
St Martin's In The Pines
Irondale, AL
1-star overall rating with 1-star inspections with 5 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Eastview Rehabilitation & Healthcare Center
Birmingham, AL
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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