Birmingham Nursing And Rehabilitation Ctr Llc
BIRMINGHAM NURSING AND REHABILITATION CTR LLC in BIRMINGHAM, AL — inspection on October 29, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
(including covering the mouth or pinching the nose to force a resident to take medication). A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ.
Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing.
After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident in order to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse.
Abuse must be reported immediately to the abuse coordinator.
Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse.
All residents would be educated on Resident's Rights.
The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated. 5.
Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]. ********** After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025.
The scope/severity level of F-F578 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birmingham Nursing and Rehabilitation Ctr LLC
1000 Dugan Avenue Birmingham, AL 35214
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
DON and Weekend Supervisor observed 5 nurses pass 5 resident's medication on 10/25/25, to ensure compliance with resident rights and medication administration procedures. No issues or concerns were identified with medication administration or the resident's right to refuse medication (including covering the mouth or pinching the nose to force a resident to take medication).
A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope[
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birmingham Nursing and Rehabilitation Ctr LLC
1000 Dugan Avenue Birmingham, AL 35214
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
Operations, the [NAME] President of Operations will guide the facility Administrator on how to implement the abuse policy to identify abuse and protect residents from perpetrators of abuse. A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ.
Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing.
After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse.
Abuse must be reported immediately to the abuse coordinator.
Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse.
All residents would be educated on Resident's Rights.
The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5.
Date of CompletionThe immediacy corrective actions were completed by [10/28/25].
Education was completed [10/28/25]. ********* After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025.
The scope/severity level of F-F607 was lowered to no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birmingham Nursing and Rehabilitation Ctr LLC
1000 Dugan Avenue Birmingham, AL 35214
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
employees off each shift to interview to ensure staff recognizes and knows whom and how to report immediately, and understand protection for residents.
The staff were asked if they understood abuse-when to report and whom to report, reporting timely, protecting the resident/intervene when the resident could be at risk and call for help. 9 out of 9 employees answered the questions correctly.
These interviews will occur weekly going forward. A Quality Assurance Meeting held on 10/24/25 to review F-tag 578, 600, 607, 609, 835, and 837 at scope and severity level IJ.
Members attending the QAPI meeting: Administrator, Human Resources, Clinical Operations Nurse, QA Nurse, [NAME] President of Operations, Medical Director, and Director of Nursing.
After receiving education (on 10/24/25 for the Administrator, DON, and [NAME] President of Operations by the [NAME] President of Clinical Services) related to abuse and covering the mouth and pinching the nose of a resident in order to prevent them from spitting out medication, the QAPI team reviewed the allegation of abuse of RI #1 by LPN #5 and the allegation was substantiated. It was determined at this meeting: The Abuse Prevention Policy will be educated to the entire staff emphasizing that any act of coercion or force (forcefully/making resident take medication against his/her will) is considered abuse.
Abuse must be reported immediately to the abuse coordinator.
Resident cannot be left alone in a potential abuse situation/unsafe situation, stay with resident, intervene, and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse.
All residents would be educated on Resident's Rights.
The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5.
Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]. ************ After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025.
The scope/severity level of F-F609 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birmingham Nursing and Rehabilitation Ctr LLC
1000 Dugan Avenue Birmingham, AL 35214
SUMMARY STATEMENT OF DEFICIENCIES
Review of RI #78's medical record did not reveal any interventions or actions were put in place to routinely supervise RI #78 to protect residents in the facility from being abused by RI #78.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birmingham Nursing and Rehabilitation Ctr LLC
1000 Dugan Avenue Birmingham, AL 35214
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
and call for help; Medication Administration Policy, residents right to refuse medication, supervisor/staff follow-up after receiving resident information that could be considered abuse.
All residents would be educated on Resident's Rights.
The DON reported to the ABON on 10/28/2025 that the allegation of abuse of RI #1 by LPN #5 was substantiated.5.
Date of CompletionThe immediacy corrective actions were completed by [10/28/25].Education was completed [10/28/25]************ After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 10/29/2025.
The scope/severity level of F-F835 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.
Facility ID: