Birmingham Nursing And Rehabilitation Ctr Llc

F-F600. Correction date 02/07/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41928

Residents Affected - Few Based on interviews, medical record review and review of a facility policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure appropriate interventions were developed to manage Resident Identifier (RI) #2's wandering behaviors and ensure residents' safety.

This deficient practice affected RI #2, one of four residents sampled for behaviors.

This deficiency was cited as a result of the investigation of complaint/report number

AL00049492.

Findings include:

A review of the Facility's policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, with a date of revision date of 2/25, documented, .

PURPOSE: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program.

DEFINITIONS: .

Behavioral Interventions are the individualized non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being.

PROCEDURE: .

2. Established resident with new onset of adverse behaviors: .

f) The Interdisciplinary Care team will update the care plan to include problem behavior, goals and approaches .

RI #1's Minimum Data Set (MDS) assessment with an Annual Reference Date (ARD) of 01/21/2025 indicated RI #1 had a Brief Interview for Mental Status (BIMS) of 11 of 15 which indicated that RI #1 had intact cognition.

RI #2 was admitted to the facility on [DATE REDACTED] with diagnosis to include Dementia without Behaviors, Alzheimer's Disease with late onset, Adjustment Disorder with Anxiety, and Mood Disorder due to Physiological Condition with Depressive Features.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 RI #2's Quarterly MDS assessment with an ARD of 08/21/2024 indicated RI #2 had a BIMS of 2 of 15 which indicated that RI #2 had severely impaired cognition. Level of Harm - Minimal harm or potential for actual harm A review of RI #2's care plan documented Focus Resident has behavior wandering into other resident's room . Date Initiated: 09/17/2024 . Goal The resident's safety will be maintained through the review date. Date Residents Affected - Few Initiated: 09/17/2024 . Interventions . Monitor resident behavior and document. Date Initiated: 09/17/2024 .

The facility's signed investigative summary dated 11/06/2024 documented, (CNA (Certified Nursing Assistant) #4) stated (RI #1) was yelling. She entered the room and noted (RI #2) standing to the right side and near the head of (RI #1)'s bed. (RI #1) stated that (RI #2) had entered (his/her) room from the bathroom. (RI #1) stated (he/she) had been yelling at (RI #2) to go back the other way and that (RI #2) had slapped (him/her) on the forehead. (RI #2 and RI #1's room) share a bathroom. (RI #2) had entered (RI #1)'s room

after using the bathroom. (RI #2) immediately did not remember the incident. (RI #1) stated (he/she) yelled and pushed against (RI #2) to prevent (RI #2) from getting in (his/her) bed. (RI #1) also stated that (he/she) did not think (RI #2) meant to hit (him/her) forehead, that (RI #2) might have stumbled as (RI #1) pushed (his/her) hand away.

A review of Investigative File, included a witness statement from RI #1. The statement was dated for 10/31/2024 at 10:05 AM. The statement documented, Q: can you tell me what happened last night? A: yes, . did not mean any harm. (He/she) came out of the bathroom the wrong way and tried to get in bed with me. I tried to push (him/her) away and (he/she) slapped me. (He/she) did not mean any harm though.

On 03/24/2025 at 4:10 PM, an interview was conducted with RI #1. RI #1 stated he/she never had a problem with another resident while at the facility and if he/she did, RI #1 would tell the Administrator. RI #1 said he/she had never been hit by another resident.

An interview was conducted with Licensed Practical Nurse (LPN) #5 on 03/25/2025 at 3:06 PM. LPN #5 stated she recalled RI #2 had two episodes of wandering into other residents' room. The one incident with RI #1 and another one about six weeks before that one. LPN #5 stated the night RI #2 wandered into RI #1's room, she was called to assist. LPN #5 stated she separated the two and conducted an assessment. LPN #5 said RI #2 was confused wandered into RI #1's room thinking that was his/her bed and tried to get in the bed. LPN #5 stated interventions implemented after the incident were observing resident more frequently and taking resident to the bathroom.

An interview was conducted with CNA #4 on 03/25/2025 at 4:25 PM. CNA #4 stated RI #2 got confused a lot. CNA #4 stated the bathroom doors confused him/her. CNA #4 stated RI #2 would go in one door and go out

the other door. CNA #4 stated when she got in the room RI #2 was standing over RI #1. CNA #4 stated she explained to RI #2 that he/she walked into the wrong room and took RI #2 back into his/her room and put to bed. CNA #4 stated the incident was reported to charge nurse then Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 On 03/26/2025 at 10:01 AM an interview was conducted with the Administrator regarding the incident. The Administrator said that RI #2 had entered the room and RI #1 told RI #2 to get out. The Administrator said Level of Harm - Minimal harm or staff heard the yelling and the residents were separated and assessed no injury noted. The Administrator potential for actual harm stated RI #2 had previous wandering behaviors and had to be redirected back to his/her room. The last incident of wandering was documented on 09/17/2024. When asked if the interventions implemented on Residents Affected - Few 09/17/2024 were effective, the Administrator stated not necessarily, that was why the facility had a Plan Do Study Act (PDSA). When asked how was the facility was monitoring RI #2, the Administrator stated staff just keeping a closer eye on RI #2 and watching where he/she was going. The Administrator stated, it was a concern when residents with behaviors that had a potential to harm to other residents were not monitored which could lead to incidents of abuse.

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The facility implemented the following corrective actions:

10/30/2024 - Residents immediately separated. RI #2 assisted back to his/her room. One-on-One supervision provided until assessed by Integrated Behavioral Health (IBH) assessed on 10/31/2024.

10/30/2024 - Body Audits conducted revealed no injuries.

10/30/2024 - MD notified. RI #1 assessed, and he/she felt safe.

10/31/2024 -Investigation started

10/31/2024- Stop sign place on RI #1's door and RI #2's name placed on their door (inside bathroom).

10/31/2024 -Trauma assessment for RI #2

10/31/2024-Behavior meeting regarding RI #2 with care plan updates. Labs completed. RI #2 positive for Urinary Tract Infection; treatment started.

10/31/2024- QAPI reviewed incident and response. Plan Do Study Act. Behavior Monitoring and Intervention Report Audit by Social Services/ADM/Nurse Management 5 times per week for 2 weeks, 3 times a week for 2 weeks, and then weekly. ADM monitor audits. Any behaviors noted on the audit to have the potential to harm ither resident will be reported to the ADM and Interdisciplinary team to determine interventions needed. QAPI will review November, December, and January 2025 for monitoring.

11/10/2024 - Education completed with all staff on Behavior Policy to include that all behaviors were potentially harmful to other residents should have immediate intervention.

11/10/2024- Education completed with all staff on Abuse Policy

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Upon review of the facility's corrective actions, it was determined the facility had implemented corrective actions from 10/30/2024 through 11/10/2024 with newly developed and ongoing monitoring to effectively prevent re-occurrence. The facility is in compliance with

F-F740.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41928 potential for actual harm Based on observations, interviews, and facility policies titled Procedure for Infection Control for Laundry Residents Affected - Many Department, and CONTACT PRECAUTIONS, the facility failed to ensure:

1)The north hall clean linen closet was clean and free from contaminants.

This deficient practice had the potential to affect one of two linen closets observed.

2) Resident's laundry was handled in a manner to prevent the spread of infection.

This deficient practice had the potential to affect 129 of 129 residents in the facility.

3) A staff member implemented Enhanced Barrier Precautions as indicated when providing care to Resident Identifier (RI) #8.

This deficient practice affected Resident Identifier (RI) #8, one of one resident reviewed for transmission-based precautions.

Findings include:

1) On 03/24/2025 at 11:51 AM, surveyor observed north hall linen closet. Surveyor observed five used dirty gloves around the closet, used tissues on both the floor and shelves, hair tracks on the floor, and hair on three PPE gowns.

On 03/24/2025 at 12:02 PM, an interview was conducted with the Infection Preventionist (IP) during an

observation of the north hall linen closet. The IP stated she saw trash on the floor, linen balled up, dirty gloves, lift pads that should be in bags, pillow that need to be in bags, hair tracks, a resident's leg brace that should not be in there, gloves in the corner, and hair on gowns. The IP said she could not tell if the items were dirty or clean. The IP stated, it looked like a nightmare in there and the closet looked that way every Monday. The IP stated the concern of the linen closet being in that condition was everything was contaminated.

2) Review of an undated facility's polity titled, Procedure for infection Control for Laundry Department, revealed, . When handling clean linen, all laundry employees will: .

not allow linen to touch their uniform or body .

Wear gloves and gowns during separation of laundry and folding laundry .

Our goal is to ensure that the facility has a consistent access to clean linen .

On 03/24/2025 at 12:16 PM, surveyor observed, the Floor Tech (FT) assisting with folding residents' laundry.

During the observation the FT was folding residents' personal clothing items with the clothing items contacting his body and clothing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 03/24/2025 at 12:28 PM, an interview was conducted with the FT. He stated when folding clothes the clothing should not touch staff's body or clothing. The FT stated the concern of clean laundry touching his Level of Harm - Minimal harm or body or clothing was cross-contamination. potential for actual harm

On 03/25/2025 at 11:08 AM, an interview was conducted with the Housekeeping Supervisor. She stated the Residents Affected - Many concern of staff allowing clean linen to come in contact with their clothing was cross-contamination.

39580

3) A review of an undated facility policy titled, CONTACT PRECAUTIONS, revealed:

POLICY:

Contact Precautions are a transmission based precaution that will be utilized to reduce the risk if transmission of epidemiologically important micro-organisms by direct or indirect contact .

DEFINTION: .

B. Enhanced Barrier Precautions expands the use of PPE (Personal Protective Equipment) beyond situations in which expose to blood or body fluids is anticipate(d), refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Bacterias) to staff hands and clothing.

EQUIPMENT:

1. Door sign that reads Contact Precautions .

PROCEDURE: .

3. Apply protective equipment as indicated upon entering the room .

The facility's door sign for EBP stated:

ENHANCED BARRIER PRECAUTIONS . STOP . PROVIDERS AND STAFF MUST ALSO: . Wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring

Changing Linens .

RI #8 was admitted to the facility on [DATE REDACTED]. RI #8 had diagnoses that included Pressure Ulcer of Right Hip, Stage 4; Pruritus; and Disorder of the Skin and Subcutaneous Tissue.

A review of RI #8's physician orders revealed an order dated 01/23/2025 for . ENHANCED BARRIER PRECAUTIONS DUE TO WOUND . The orders also contained an order for wound care to be provided for . PRESSURE ULCER OF RIGHT HIP, STAGE 4 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 015217 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015217 B. Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Birmingham Nursing and Rehabilitation Ctr LLC 1000 Dugan Avenue Birmingham, AL 35214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 03/24/2024 at 4:13 PM an observation was made of CNA #3 as she entered RI #8's room without applying a gown. RI #8's door had the facility's sign which indicated that RI #8 was on EBP. CNA #3 was Level of Harm - Minimal harm or observed making contact with RI #8, the bed's linen, and the bed. CNA #3 repositioned resident up in the potential for actual harm bed and covered RI #8 with a blanket.

Residents Affected - Many On 03/24/2025 at 4:14 PM, an interview was conducted with CNA #3 who said that RI #8 had an EBP sign

on his/her door. CNA #3 said she was only wearing gloves when she repositioned RI #8 up in the bed. CNA #3 said she would don (put on) gloves only (not a gown) if she performed perineal care or bathed RI #8 unless resident was on a certain precaution that would require her wearing more PPE. CNA #3 said RI #8 was not on any type of precautions.

On 03/26/2025 at 4:24 PM, an interview was conducted with the Infection Preventionist Nurse (IPN) who said RI #8 was on EBP for his/her wound. The IPN said signage was placed on RI #8's door to alert staff that EBP was in place and so the staff would know what type of PPE should be worn. The IPN said according to

the facility's policy staff should don gloves and gown when entering a resident's room with EBP to prevent

the spread of germs from one resident to another and cross-contamination. The IPN said for a resident on EBP staff should wear gloves and a gown when repositioning the resident and adjusted his/her linen. The IPN said staff not wearing the appropriate PPE for residents with EBP was an infection control concern.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 015217