Irondale, AL

St Martin's In The Pines

1-star overall rating with 1-star inspections with 5 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle

4941 Montevallo Road, Irondale, AL

(205) 956-1831

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 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

128

Certified beds

Average residents

97

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Diversicare Healthcare

Operator or chain grouping

Approved since

1997-07-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

44 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

0.56

Registered nurse staffing · state 0.64 · national 0.68

LPN hours / resident day

0.67

Licensed practical nurse staffing · state 0.78 · national 0.87

Aide hours / resident day

3.00

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

1.23

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

0.40

Weekend registered nurse coverage · state 0.36 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

4.42

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,478

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

32.70

Composite VBP score used to determine payment impact.

Payment multiplier

0.9872

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.70% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.69

Baseline 6.38% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0

Total nurse turnover

3.35

Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

6.05

Baseline 5.81 hours · Performance 4.80 hours · Measure score 6.05 · Achievement 6.05 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.81%
10.72%
1.1 pts worse
No Different than the National Rate · Eligible stays 95 · Observed rate 12.63% · Lower 95% interval 8.23%
Discharge to community 41.69%
50.57%
8.9 pts worse
No Different than the National Rate · Eligible stays 85 · Observed rate 34.12% · Lower 95% interval 33.8%
Medicare spending per beneficiary 0.91
1.02
0.1 pts better
Drug regimen review with follow-up 95.6%
95.27%
0.3 pts better
Numerator 87 · Denominator 91
Falls with major injury 1.1%
0.77%
0.3 pts worse
Numerator 1 · Denominator 91
Discharge self-care score 35.38%
53.69%
18.3 pts worse
Numerator 23 · Denominator 65
Discharge mobility score 27.69%
50.94%
23.2 pts worse
Numerator 18 · Denominator 65
Pressure ulcers or injuries, new or worsened 3.3%
2.29%
1 pts worse
Numerator 3 · Denominator 91 · Adjusted rate 3.28%
Healthcare-associated infections requiring hospitalization 6.73%
7.12%
0.4 pts better
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 4.03%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 99
Staff flu vaccination coverage 29.19%
42%
12.8 pts worse
Numerator 47 · Denominator 161
Discharge function score 32.31%
56.45%
24.1 pts worse
Numerator 21 · Denominator 65
Transfer of health information to provider 95.65%
95.95%
0.3 pts worse
Numerator 44 · Denominator 46
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 6.67%
25.2%
18.5 pts worse
Numerator 3 · Denominator 45

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.2
2.0
0.8 pts better
1.9
0.7 pts better
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.7
1.8
0.1 pts better
1.8
0.1 pts better
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 21.5%
91.3%
69.8 pts worse
93.4%
71.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 13.9% · Q3 21.3% · Q4 41.3% · 4Q avg 21.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 87.2%
94.8%
7.6 pts worse
95.5%
8.3 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.2%
Percentage of long-stay residents experiencing one or more falls with major injury 3.0%
3.4%
0.4 pts better
3.3%
0.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.8% · Q3 2.7% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 1.9%
1.3%
0.6 pts worse
11.4%
9.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight 17.1%
5.3%
11.8 pts worse
5.4%
11.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 22.4% · Q3 18.2% · Q4 19.3% · 4Q avg 17.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 24.1%
24.9%
0.8 pts better
19.6%
4.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 25.0% · Q3 25.0% · Q4 22.4% · 4Q avg 24.1%
Percentage of long-stay residents who received an antipsychotic medication 17.3%
22.8%
5.5 pts better
16.7%
0.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 19.6% · Q3 16.7% · Q4 22.4% · 4Q avg 17.3% · 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 31.4%
14.8%
16.6 pts worse
16.3%
15.1 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 16.1%
13.4%
2.7 pts worse
14.9%
1.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 14.5% · Q3 7.7% · Q4 17.9% · 4Q avg 16.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.1%
1.3%
0.2 pts better
1.0%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.4%
2.6%
0.2 pts better
1.7%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.3% · Q3 0.0% · Q4 5.4% · 4Q avg 2.4% · 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 15.6% · Q2 13.7% · Q3 10.6% · Q4 13.8% · 4Q avg 13.3%
Percentage of long-stay residents with pressure ulcers 3.9%
5.7%
1.8 pts better
5.1%
1.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.5% · Q3 4.5% · Q4 1.9% · 4Q avg 3.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 22.6%
84.3%
61.7 pts worse
81.7%
59.1 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 22.4% · Q3 26.6% · Q4 32.7% · 4Q avg 22.6%
Percentage of short-stay residents who had an outpatient emergency department visit 6.1%
11.5%
5.4 pts better
12.0%
5.9 pts better
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.9% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.7%
2.1%
0.6 pts worse
1.6%
1.1 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.2% · Q3 1.8% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 31.3%
80.3%
49 pts worse
79.7%
48.4 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 23.0%
24.5%
1.5 pts better
23.9%
0.9 pts better
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 22.1% · Expected 22.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2019-10-03 · Fire 2019-10-03

5 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (9 deficiencies)

Cycle 2 Health 2018-09-26 · Fire 2018-09-26

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

21 fire-safety deficiencies

Top issue: Smoke (9 deficiencies)

Cycle 3 Health 2017-08-24 · Fire 2017-08-24

6 health deficiencies

Top issue: Environmental (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2019-10-03

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-11-12

E · Potential for more than minimal harm 2019-10-03

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-11-12

E · Potential for more than minimal harm 2019-10-03

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2019-11-12

E · Potential for more than minimal harm 2019-10-03

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-10-10

E · Potential for more than minimal harm 2019-10-03

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-10-21

D · Potential for more than minimal harm 2019-10-03

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2019-10-29

D · Potential for more than minimal harm 2019-10-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2019-10-31

D · Potential for more than minimal harm 2019-10-03

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2019-11-12

D · Potential for more than minimal harm 2019-10-03

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-11-12

F · Potential for more than minimal harm 2018-09-26

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2018-11-08

F · Potential for more than minimal harm 2018-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-11-08

F · Potential for more than minimal harm 2018-09-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2018-11-08

F · Potential for more than minimal harm 2018-09-26

K373 · Smoke Deficiencies

Fire Safety

Have enough space near smoke barriers to protect residents.

Corrected 2018-11-08

F · Potential for more than minimal harm 2018-09-26

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2018-11-08

F · Potential for more than minimal harm 2018-09-26

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 2018-11-08

F · Potential for more than minimal harm 2018-09-26

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2018-11-08

E · Potential for more than minimal harm 2018-09-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2018-11-08

E · Potential for more than minimal harm 2018-09-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2018-11-08

E · Potential for more than minimal harm 2018-09-26

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-11-08

E · Potential for more than minimal harm 2018-09-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

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 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2018-11-08

D · Potential for more than minimal harm 2018-09-26

K751 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of flammable curtains.

Corrected 2018-11-08

C · Minimal harm 2018-09-26

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2018-11-08

F · Potential for more than minimal harm 2017-08-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2017-10-05

E · Potential for more than minimal harm 2017-08-24

K373 · Smoke Deficiencies

Fire Safety

Have enough space near smoke barriers to protect residents.

Corrected 2017-10-05

D · Potential for more than minimal harm 2017-08-24

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2017-10-05

D · Potential for more than minimal harm 2017-08-24

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2017-10-05

D · Potential for more than minimal harm 2017-08-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2017-10-05

D · Potential for more than minimal harm 2017-08-24

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2017-10-05

Inspection history

Recent health citations

K · Immediate jeopardy 2025-07-18

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 2025-08-26

D · Potential for more than minimal harm 2025-07-18

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 2025-08-26

D · Potential for more than minimal harm 2025-07-18

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-08-26

E · Potential for more than minimal harm 2019-10-03

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 2019-11-06

D · Potential for more than minimal harm 2019-10-03

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 2019-11-06

D · Potential for more than minimal harm 2018-09-26

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2018-10-19

D · Potential for more than minimal harm 2018-09-26

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 2018-10-19

F · Potential for more than minimal harm 2017-08-24

F371 · Nutrition and Dietary Deficiencies

Health

Store, cook, and serve food in a safe and clean way.

Corrected 2017-09-28

F · Potential for more than minimal harm 2017-08-24

F372 · Environmental Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2017-09-28

E · Potential for more than minimal harm 2017-08-24

F279 · Resident Assessment and Care Planning Deficiencies

Health

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2017-09-28

D · Potential for more than minimal harm 2017-08-24

F282 · Quality of Life and Care Deficiencies

Health

Provide care by qualified persons according to each resident's written plan of care.

Corrected 2017-09-28

D · Potential for more than minimal harm 2017-08-24

F369 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for each resident who needs them.

Corrected 2017-09-28

D · Potential for more than minimal harm 2017-08-24

F441 · Environmental Deficiencies

Health

Have a program that investigates, controls and keeps infection from spreading.

Corrected 2017-09-28

Penalties and ownership

What sits behind the stars

$0 2025-07-18

Payment Denial

Payment Denial · denial start 2025-08-29 · 3 days

3 day denial

Ownership

Pines Opco Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2023-11-17
Bodie, Rebecca

Corporate Officer · Individual

0% 41 facilities 2023-11-17
Dac Acquisition LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 39 facilities 2022-01-12
Dac Opco, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 5 facilities 2023-10-31
Diversicare Management Services LP.

Operational/Managerial Control · Organization

0% 38 facilities 2023-11-17
El Pines LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 1 facilities 2023-10-31
Kellman, Franklin

Corporate Director · Individual

0% 35 facilities 2024-09-13
Kohn, Brian

Corporate Director · Individual

0% 47 facilities 2023-11-17
Nee, Stephen

Corporate Officer · Individual

0% 43 facilities 2023-11-17
Ratner, Eran

Corporate Director · Individual

0% 40 facilities 2023-11-17
Ratner, Eran

Corporate Officer · Individual

0% 40 facilities 2024-09-13
Rudemiller, Kyle

Contracted Managing Employee · Individual

0% 1 facilities 2024-02-01
Stocker, Becky

W-2 Managing Employee · Individual

0% 1 facilities 2024-10-21
Weishaar, Matthew

Corporate Officer · Individual

0% 46 facilities 2023-11-17

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