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

ST MARTIN'S IN THE PINES

IRONDALE, AL · 128 certified beds · Last Life Safety survey October 3, 2019

CMS Certification Number 015433 · first certified July 1997

Ownership

Operated by DIVERSICARE HEALTHCARE · Non profit - Church related

Ownership changed November 17, 2023 (change of ownership)from EPISCOPAL FOUNDATION OF JEFFERSON COUNTY

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within AL

42 citations — more than 100% 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 15 citations; the earlier surveys in the window averaged 13.5. 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 2020 to March 2021), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was October 2019. 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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6 inspection-and-testing tags have 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

1 of the 42 citations on file is 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

E-0025

Physical environment (health survey)

1 physical-environment citation 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 42 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

Citations on file over three years, compared
Measure	Citations
This facility	42
Median facility in AL	9
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 24, 2017	6
September 26, 2018	21
October 3, 2019	15

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0920	Ensure proper usage of power strips and extension cords.	2	2019-10-03
K-0351	Install an approved automatic sprinkler system.	2	2019-10-03
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	2	2019-10-03
K-0324	Provide properly protected cooking facilities.	2	2019-10-03
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2019-10-03
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2019-10-03
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2019-10-03
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	2	2019-10-03

What the citations cover

Citations by CMS category

Smoke Deficiencies 21
Miscellaneous Deficiencies 8
Egress Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 5
Other 3

Citations by CMS category
Category	Citations
Smoke Deficiencies	21
Miscellaneous Deficiencies	8
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	5
Services Deficiencies	2
Emergency Preparedness Deficiencies	1

Every citation on file

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

October 3, 2019 — 15 citations

Citations issued on October 3, 2019
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (November 12, 2019)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (November 12, 2019)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (November 12, 2019)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 12, 2019)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 21, 2019)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 29, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 12, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (October 31, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 10, 2019)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (November 12, 2019)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (November 12, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (November 12, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (November 12, 2019)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (November 12, 2019)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (November 12, 2019)

September 26, 2018 — 21 citations

Citations issued on September 26, 2018
Tag	What the surveyor checks	Status
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (November 8, 2018)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (November 8, 2018)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (November 8, 2018)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (November 8, 2018)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (November 8, 2018)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (November 8, 2018)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (November 8, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 8, 2018)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (November 8, 2018)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (November 8, 2018)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 8, 2018)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (November 8, 2018)
K-0373	Have enough space near smoke barriers to protect residents.	Deficient, Provider has date of correction (November 8, 2018)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (November 8, 2018)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (November 8, 2018)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (November 8, 2018)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (November 8, 2018)
K-0751	Have restrictions on the use of flammable curtains.	Deficient, Provider has date of correction (November 8, 2018)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (November 8, 2018)
K-0914	Ensure 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, 2018)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (November 8, 2018)

August 24, 2017 — 6 citations

Citations issued on August 24, 2017
Tag	What the surveyor checks	Status
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 5, 2017)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (October 5, 2017)
K-0373	Have enough space near smoke barriers to protect residents.	Deficient, Provider has date of correction (October 5, 2017)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (October 5, 2017)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 5, 2017)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 5, 2017)

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