Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birmingham Nursing And Rehabilitation Ctr Llc during CMS and state inspections, most recent first.
A resident with severe mental illness and behavioral disturbances physically struck two other residents on separate occasions in the dining room. Despite a history of unpredictable and aggressive behaviors, the care plans lacked specific supervision interventions, and no assessment was conducted to determine the necessary level of supervision after the first incident. Multiple staff were present but did not witness the abuse until after it occurred, and the facility did not adequately analyze or address the causes to prevent recurrence.
A resident with severe mental illness and dementia, known for unpredictable and aggressive behaviors, was not adequately supervised or provided with individualized behavioral interventions. This lack of supervision led to two incidents where the resident physically struck other residents, with staff and witness interviews confirming the actions were linked to delusional thinking. Facility records and care plans did not reflect ongoing supervision or updated interventions despite the resident's history and repeated incidents.
A resident with severe cognitive impairment was subjected to physical and mental abuse when an LPN placed a hand over the resident's mouth and pinched the nose to force medication administration, despite the resident's right to refuse treatment. The incident was witnessed by a CNA, and subsequent staff interviews confirmed that such actions were improper and could be considered abuse. Facility policies clearly state residents' rights to refuse care, but the LPN admitted to the coercive act, and the facility failed to provide adequate oversight upon the LPN's return to work.
A resident with severe cognitive impairment was physically and mentally abused by an LPN during medication administration, when the LPN covered the resident's mouth and pinched their nose to force medication intake. A CNA witnessed the incident but failed to intervene or report it immediately, and the LPN continued working without supervision. Facility administration did not initially identify the event as abuse, allowing the LPN to return to work and administer medications to other vulnerable residents without monitoring.
A resident with severe cognitive impairment was subjected to physical and mental abuse by an LPN, who attempted to force medication administration by pinching the resident's nose and covering their mouth. A CNA witnessed the incident but did not immediately intervene or report it, leaving the resident alone with the LPN. The facility failed to suspend the LPN as required by policy, allowing the LPN to continue working and placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and staff interviews confirmed that abuse prevention and reporting protocols were not followed.
A CNA failed to immediately report an observed incident where an LPN used physical force to administer medication to a resident with severe cognitive impairment, resulting in a delay in notifying facility administration and the State Agency. The LPN continued working without oversight, and staff interviews confirmed a lack of understanding regarding immediate abuse reporting requirements.
The facility failed to maintain cleanliness in a linen closet and did not handle residents' laundry properly, risking contamination. A staff member also neglected to follow Enhanced Barrier Precautions for a resident with a Stage 4 pressure ulcer, entering the room without a gown despite signage indicating the need for such precautions.
Two residents in a facility engaged in a physical altercation over a misunderstanding involving a bag of chips. Both residents were cognitively intact, and the incident was witnessed by a CNA who intervened. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from physical abuse by others.
A resident with severely impaired cognition wandered into another resident's room, leading to a physical altercation. The facility failed to implement effective interventions to manage the resident's wandering behavior, despite a history of similar incidents. The care plan lacked appropriate measures to prevent such occurrences, resulting in a deficiency citation.
A resident with COPD had their nebulizer mask uncovered and tubing undated, contrary to facility protocols. Staff confirmed that the nebulizer tubing should be changed and dated weekly, and the mask should be covered and dated when not in use. The lack of adherence to these protocols could lead to bacterial growth.
A CNA at a long-term care facility borrowed $250 from a resident, violating facility policy against accepting loans from residents. The resident, who was cognitively intact, reported the incident after the CNA failed to repay the loan as agreed. The CNA admitted to the transaction and was terminated following an investigation.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to protect residents from physical abuse perpetrated by another resident with a known history of severe mental illness and behavioral disturbances. One resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, Dementia with Behavioral Disturbance, and severely impaired cognition, was involved in two separate incidents where they physically struck other residents in the dining room. The first incident involved this resident approaching and hitting another resident on the right upper arm without provocation, and the second incident involved the same resident getting up from their chair and hitting a different resident on the left shoulder during a meal. Despite the resident's documented history of unpredictable and aggressive behaviors, including resistance to care, verbal aggression, and poor impulse control, the care plans did not include specific interventions or guidance for staff regarding the level of supervision required to prevent further abuse. Staff interviews confirmed that the resident's behaviors were unpredictable and that constant supervision would be necessary to prevent such incidents. However, after initial one-to-one supervision was discontinued following the first incident, no assessment was conducted to determine the ongoing level of supervision needed, and the resident was able to commit a second act of physical abuse. The facility's investigative files and staff interviews revealed that during both incidents, multiple staff members were present in the dining room, but most were unaware of the abusive acts until after they occurred. Only one staff member witnessed each event directly. The facility did not analyze or review the incidents in a manner that would determine the underlying causes or implement effective corrective actions to prevent recurrence, resulting in repeated abuse affecting multiple residents.
Failure to Supervise Resident with Psychosis Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate behavioral health interventions for a resident with a known history of chronic delusions, psychosis, restlessness, agitation, and aggressive behaviors. This resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, and Dementia with Behavioral Disturbance, exhibited impaired cognition and was documented as resistant to care, wandering, and receiving antipsychotic medication. Despite these known risk factors and a history of unpredictable and aggressive behaviors, the facility did not consistently implement or document supervision or individualized interventions to prevent harm to other residents. Two separate incidents occurred in which the resident physically struck other residents on the shoulder. In both cases, the actions were linked to the resident's delusional thinking and psychosis, as evidenced by statements made during investigations and interviews with staff and witnesses. Staff interviews confirmed that the resident's behaviors were unpredictable and that effective prevention would require close or one-to-one supervision when the resident was in common areas with others. However, the facility's records and care plans did not reflect ongoing or routine supervision or specific interventions to address the risk of harm to others, despite the resident's established behavioral history and previous incidents. Facility policies on abuse prevention and behavior management required individualized assessment and intervention for residents with behaviors that could harm themselves or others. However, after the initial incident, there was no documented assessment to determine the appropriate level of supervision needed for the resident, and the care plan was not updated to reflect the physical aggression. The lack of consistent supervision and failure to update care plans or implement effective interventions resulted in repeated incidents of resident-to-resident abuse, as observed and reported by staff and documented in investigative files.
Resident Rights Violated During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered medication to a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease. During the medication administration, the LPN placed his hand over the resident's mouth and pinched the resident's nose to prevent the resident from spitting out the medication. This act was witnessed by a Certified Nursing Assistant (CNA), who observed the resident's face turning red and the resident struggling and moving their head from side to side in response to the force used by the LPN. The CNA considered the LPN's actions to be abusive and left the room to report the incident. Interviews with other staff members, including additional LPNs, the Unit Manager, the Social Worker, and the Director of Nursing (DON), confirmed that the resident had the right to refuse medication and that placing a hand over a resident's mouth to force medication was improper, could be considered abuse, and posed a risk of aspiration. The facility's own policies on medication administration and the Resident Bill of Rights explicitly state that residents have the right to refuse treatment and must not be subjected to coercion or force. Despite this, the LPN admitted to placing his hand over the resident's mouth to prevent the medication from being spit out, acknowledging that this was not appropriate and that the resident should have been allowed to refuse the medication. Following the incident, it was revealed that the LPN was suspended but returned to work without direct monitoring or oversight. There was no evidence that the facility took steps to ensure that the LPN did not repeat this behavior with other residents during medication administration. The lack of immediate and ongoing supervision after the incident, combined with the failure to protect the resident's right to refuse care, led to the citation of Immediate Jeopardy under F578 for violation of resident rights.
Abuse During Medication Administration and Failure to Protect Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease was subjected to physical and mental abuse by an LPN during medication administration. The LPN placed his hand and a paper towel over the resident's mouth and pinched the resident's nose to force the resident to swallow medication, while telling the resident to take the medication. This act was witnessed by a CNA, who observed the resident's face turning red and the resident struggling and moving their head from side to side. The CNA left the room, leaving the resident alone with the LPN, and did not immediately report the incident. The LPN continued to work his scheduled shift after the incident, as the facility administration did not immediately identify the event as abuse or take appropriate corrective action to protect residents. The LPN was only suspended after administration was made aware of the incident later in the day. Despite the seriousness of the event, the LPN was allowed to return to work after a brief suspension and was not monitored or supervised while administering medications to other vulnerable residents, including those with dementia, who could be at risk of similar abuse. Interviews with staff familiar with the resident confirmed that the LPN's actions were physically, emotionally, and psychologically abusive, and could have resulted in aspiration. The responsible party for the resident stated that having a hand placed over the resident's mouth would have caused significant fear. The facility's failure to recognize, report, and respond appropriately to the abuse, as well as the lack of monitoring of the LPN after the incident, resulted in a finding of immediate jeopardy due to the likelihood of serious injury, harm, impairment, or death to residents.
Failure to Implement Abuse Prevention Policy and Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and did not take appropriate actions to protect a resident from abuse by an LPN. On the morning of the incident, the LPN was observed by a CNA placing a paper towel over the resident's nose and pinching it, while also covering the resident's mouth, in an attempt to force the resident to swallow medications. The resident, who had a history of severe cognitive impairment and multiple medical diagnoses including acute respiratory failure, dementia, and cerebrovascular disease, was left alone with the LPN after the CNA witnessed the event. The CNA did not immediately intervene or report the abuse, instead leaving the room and only reporting the incident to the DON several hours later. Despite the facility's policy requiring immediate suspension of any employee accused of abuse and immediate reporting, the LPN continued to work and administer medications to residents during the survey period, placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and the LPN was allowed to return to work after a brief suspension. The facility's failure to recognize and act upon the abuse allegation resulted in the LPN maintaining access to residents for over a month after the incident. Interviews with staff revealed a lack of timely reporting and intervention in response to the witnessed abuse. The CNA who observed the incident did not follow the facility's abuse policy for protecting residents, and other staff members did not take immediate action when informed of the situation. The facility's leadership, including the DON and Administrator, acknowledged that the abuse policy was not followed and that the resident was not adequately protected from potential harm.
Failure to Immediately Report and Intervene in Observed Resident Abuse
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to immediately report an observed incident of abuse involving a resident with severe cognitive impairment. The incident involved a Licensed Practical Nurse (LPN) who placed his hands over the resident's mouth and nose, using a paper towel to pinch the nose, in an attempt to force the resident to swallow medication. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, cerebrovascular disease, and pain, was observed struggling, turning red in the face, and pushing their head from side to side during the incident. The CNA, after witnessing this, initially attempted to inform another LPN, who declined to get involved, and then delayed reporting the incident to facility administration. The facility's policy required that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the administrator or other officials. In this case, the CNA did not report the incident to the Director of Nursing (DON) until several hours after the event, and the abuse was not reported to the State Agency until later that day. During this time, the LPN involved continued to work his shift without direct monitoring or oversight. Interviews with staff confirmed that the CNA did not understand the importance of immediate reporting and that other staff members did not intervene or ensure the report was made promptly. The delay in reporting and failure to protect the resident from further potential harm constituted a violation of the facility's abuse prevention policy. The deficiency was substantiated through interviews, record reviews, and examination of the facility's own investigative documentation. The incident affected one resident who was sampled for abuse, and the failure to report and intervene as required placed the resident at risk.
Infection Control Deficiencies in Linen Handling and Barrier Precautions
Penalty
Summary
The facility failed to maintain cleanliness and prevent contamination in the north hall clean linen closet, as observed by the surveyor. The closet contained used dirty gloves, tissues, hair tracks, and hair on PPE gowns, indicating a lack of proper sanitation. The Infection Preventionist acknowledged the contamination and described the closet's condition as a 'nightmare,' noting that it appeared this way every Monday. This deficiency had the potential to affect one of the two linen closets observed, posing a risk of contamination. Additionally, the facility did not handle residents' laundry in a manner that prevented the spread of infection. A Floor Tech was observed folding residents' personal clothing items in a way that allowed them to contact his body and clothing, contrary to the facility's policy. Both the Floor Tech and the Housekeeping Supervisor recognized the risk of cross-contamination from this practice. Furthermore, a staff member failed to implement Enhanced Barrier Precautions for a resident with a Stage 4 pressure ulcer, as required by the facility's policy. The CNA entered the resident's room without wearing a gown, despite the presence of a sign indicating Enhanced Barrier Precautions. The Infection Preventionist Nurse confirmed that the staff should have worn gloves and a gown to prevent cross-contamination.
Resident Altercation Due to Misunderstanding Over Personal Belongings
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in a physical altercation between them. The incident occurred when a Certified Nursing Assistant (CNA) was transferring one resident back to their room, and the other resident hit them, leading to a fight. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. The residents involved were both cognitively intact, with one having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and the other 11 out of 15. The altercation began when one resident noticed a bag of chips in the other's possession and attempted to take it, leading to a physical confrontation. The CNA witnessed the incident and intervened by separating the residents and calling for the charge nurse. Interviews with the residents and staff revealed that the altercation was triggered by a misunderstanding over personal belongings, specifically a bag of chips. The facility's investigation confirmed that the residents hit each other on the arms during the incident. The facility's failure to prevent this altercation highlights a deficiency in ensuring residents are free from physical abuse by other residents.
Failure to Manage Resident Wandering Behaviors
Penalty
Summary
The facility failed to ensure appropriate interventions were developed to manage a resident's wandering behaviors, which compromised the safety of other residents. The resident in question, identified as having severely impaired cognition, was admitted with diagnoses including Dementia without Behaviors, Alzheimer's Disease with late onset, Adjustment Disorder with Anxiety, and Mood Disorder due to Physiological Condition with Depressive Features. Despite these conditions, the resident's care plan only included monitoring and documenting behavior without effective interventions to prevent wandering into other residents' rooms. An incident occurred where the resident wandered into another resident's room through a shared bathroom, leading to a confrontation. The resident was found standing near the head of another resident's bed, which resulted in a physical altercation where the wandering resident inadvertently slapped the other resident. Interviews with staff revealed that the wandering resident had a history of entering other residents' rooms, and the interventions in place were not sufficient to prevent such incidents. The facility's policy on behavior management required the development of a behavior program for residents with behaviors that could harm themselves or others. However, the facility did not effectively update the care plan with appropriate interventions after the resident's wandering behavior was identified. The staff's response to the incident involved separating the residents and assessing them for injuries, but the lack of proactive measures to address the wandering behavior led to the deficiency being cited.
Failure to Maintain Proper Respiratory Care Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident diagnosed with Chronic Obstructive Pulmonary Disease. The resident's nebulizer mask was observed uncovered and without a date on the tubing on multiple occasions. Specifically, on two separate days, the nebulizer was found at the resident's bedside without a cover, and the tubing lacked a date, which is necessary to verify when it was last changed. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the nebulizer tubing should be changed and dated weekly, and the mask should be covered and dated when not in use. The staff acknowledged that the absence of a date on the tubing and the lack of a cover on the mask could lead to bacterial growth, posing a risk to the resident's health. The facility's protocol for verifying tubing changes involves the QA nurse checking the dates, which was not adhered to in this instance.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds by a staff member. The incident involved a Certified Nursing Assistant (CNA) who borrowed $250 from a resident, identified as Resident Identifier (RI) #1, without repaying it as initially agreed. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported the incident to the Business Office Manager (BOM) after the repayment was delayed. The facility's policies, including the Abuse Prevention and Human Resources Management Policy, explicitly prohibit staff from accepting loans from residents. Despite being aware of this policy, the CNA borrowed money from the resident, which constitutes misappropriation of resident property. The incident was reported to the Alabama Department of Public Health (ADPH) and was part of a complaint investigation. The resident had been discharged from the facility prior to reporting the incident. During interviews, both the resident and the CNA confirmed the loan transaction. The CNA admitted to borrowing the money and acknowledged that it was against the facility's policy. The facility administrator was informed of the incident, and an investigation was initiated, leading to the CNA's termination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Birmingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Hill Rehabilitation & Healthcare Center | 1.8 mi | — | 0 | 0 |
| Oak Knoll Health And Rehabilitation, Llc | 3.2 mi | — | 0 | 0 |
| Arlington Rehabilitation & Healthcare Center | 4.1 mi | — | 0 | 0 |
| Civic Center Health And Rehabilitation, Llc | 4.4 mi | — | 0 | 0 |
| Northway Health And Rehabilitation, Llc | 4.4 mi | — | 0 | 0 |
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