Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

KIRKWOOD BY THE RIVER

BIRMINGHAM, AL · 61 certified beds · Last Life Safety survey October 7, 2021

CMS Certification Number 015457 · first certified September 2006

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

11
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
5
Inspection & testing records
Of the citations on file

Position within AL

11 citations — more than 58% of the 224 certified nursing homes in AL. Compared within AL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 7 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (October 2022 to March 2023), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was October 2021. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. AL has too few recent surveys to measure on its own, so the national interval is used.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 11 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in AL, and nationally. Surveyors differ markedly between states, so the AL figure is the meaningful one.

This facility11AL median9National median11
Citations on file over three years, compared
MeasureCitations
This facility11
Median facility in AL9
Median facility nationally11

Survey history

Citations at each Life Safety survey
22018-0322019-0372021-10
Citations at each Life Safety survey
Survey dateCitations
March 22, 20182
March 28, 20192
October 7, 20217

Most-cited tags

Most-cited tags at this facility
K-03532K-09231E-00411K-03741K-03511K-03631K-02931E-00391
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.22019-03-28
K-0923Have proper medical gas storage and administration areas.12021-10-07
E-0041Implement emergency and standby power systems.12021-10-07
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.12021-10-07
K-0351Install an approved automatic sprinkler system.12018-03-22
K-0363Install corridor and hallway doors that block smoke.12021-10-07
K-0293Have properly located and lighted "Exit" signs.12021-10-07
E-0039Conduct testing and exercise requirements.12019-03-28

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Emergency Preparedness Deficiencies 2
  • Egress Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies2
Emergency Preparedness Deficiencies2
Egress Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 7, 2021 — 7 citations

Citations issued on October 7, 2021
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (November 8, 2021)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (November 8, 2021)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (November 8, 2021)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (November 8, 2021)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (November 8, 2021)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (November 8, 2021)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (November 8, 2021)

March 28, 2019 — 2 citations

Citations issued on March 28, 2019
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (May 7, 2019)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 7, 2019)

March 22, 2018 — 2 citations

Citations issued on March 22, 2018
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (April 4, 2018)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 4, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.