Inspection Reports for
Birmingham Rehabilitation and Wellness Center

The complaint investigation was triggered by reports of physical abuse incidents on 06/12/2025 and 09/15/2025 involving resident RI #78 hitting residents RI #119 and RI #13. The allegations were substantiated based on witness statements, interviews, and facility investigations.

The facility failed to protect residents from physical abuse by another resident with known behavioral health issues. RI #78 was witnessed hitting RI #119 and RI #13 on separate occasions. The facility failed to assess and determine the appropriate level of supervision needed for RI #78 to prevent further abuse, and corrective actions were insufficient to prevent recurrence. The abuse allegations were substantiated.

The complaint investigation was triggered by Facility Reported Incidents alleging physical abuse by resident RI #78 against residents RI #119 on 06/12/2025 and RI #13 on 09/15/2025. Both allegations were substantiated after investigation. The facility failed to prevent recurrence due to inadequate supervision and lack of assessment of supervision needs.

The facility failed to protect residents from physical abuse by resident RI #78, who had a history of severe mental illness and behavioral disturbances. RI #78 was witnessed hitting two residents on separate occasions, and the facility failed to assess and determine the appropriate level of supervision needed to prevent further abuse. The abuse allegations were substantiated, and the facility did not implement adequate interventions or supervision to manage RI #78's behaviors and ensure resident safety.

The complaint involved allegations of abuse and mistreatment of RI #1 by LPN #5 on 09/19/2025, including forcibly administering medication by covering the resident's mouth and pinching the nose. The CNA witness delayed reporting and failed to intervene. The facility initially failed to substantiate the abuse and allowed LPN #5 to return to work without monitoring. The abuse was later substantiated after investigation and education. The complaint number was 2623504.

The facility failed to protect RI #1 from physical and mental abuse by LPN #5 who placed his hand over the resident's mouth and pinched the nose to prevent spitting out medication. The Certified Nursing Assistant (CNA) who witnessed the abuse failed to report it immediately. The facility did not monitor or supervise LPN #5 after the incident, allowing continued risk to residents. The abuse was substantiated and immediate jeopardy was cited but later removed after corrective actions were implemented. Additional findings included failure to timely report abuse, inadequate staff education, and failure to provide adequate supervision for a resident with behavioral health needs who physically abused other residents.

The complaint involved allegations of physical and mental abuse of RI #1 by LPN #5 on 09/19/2025, specifically forced medication administration by covering the resident's mouth and pinching the nose. The complaint was substantiated after investigation. The CNA witness delayed reporting and failed to intervene. The facility initially failed to identify the incident as abuse and allowed LPN #5 to return to work without monitoring. The immediate jeopardy was removed after corrective actions on 10/29/2025.

The facility failed to protect RI #1's rights and ensure freedom from abuse when LPN #5 forcibly administered medication by placing his hand over the resident's mouth and pinching the nose, causing immediate jeopardy. The Certified Nursing Assistant (CNA) witness failed to intervene or report timely. The facility also failed to monitor LPN #5 upon his return to work. The abuse was substantiated, corrective actions were implemented, and immediate jeopardy was removed on 10/29/2025. Additional findings included failure to timely report abuse, inadequate staff oversight, and failure to implement abuse prevention policies effectively.

The complaint investigations involved report numbers AL00050195 related to resident abuse between RI #3 and RI #4, and AL00049492 related to behavioral health care deficiencies for RI #2.

The facility failed to prevent resident-to-resident physical abuse involving two residents, failed to develop appropriate interventions for managing wandering behaviors of another resident, and failed to implement proper infection prevention and control practices including improper use of PPE and contamination in linen closets. Corrective actions and staff education were implemented following these findings.

The complaint investigation involved report number AL00050195 related to resident-on-resident physical abuse involving RI #3 and RI #4, and report number AL00049492 related to inadequate behavioral health care for RI #2. The investigation also included infection control concerns.

The facility was found deficient in protecting residents from physical abuse between residents, managing behavioral health care for residents with wandering behaviors, and implementing infection prevention and control protocols including proper use of enhanced barrier precautions and handling of clean linen.

The facility failed to ensure that Resident #26's nebulizer mask was stored in a bag and dated, and the nebulizer tubing was not dated as required. This posed a risk of bacterial growth and potential harm to residents.

The facility failed to ensure that Resident #26's nebulizer mask was stored in a bag and dated, and the nebulizer tubing was not dated, which could lead to bacterial growth. Observations and interviews confirmed these deficiencies related to respiratory care equipment maintenance.

The complaint investigation involved Resident #1 who reported loaning $250 to CNA #1, who had not repaid the loan as intended by 05/24/2024. The incident was reported to the Alabama Department of Public Health (ADPH) on 05/28/2024. The CNA repaid the loan on 05/28/2024 and was terminated from employment. Resident #1 was cognitively intact and satisfied with the resolution.

The facility failed to protect Resident #1 from misappropriation of funds when CNA #1 borrowed $250 and delayed repayment. The CNA was terminated, the loan was repaid, and corrective actions including staff education and resident council discussions were implemented.

The complaint investigation was triggered by report number AL00048072 and AL00047985 regarding CNA #1 borrowing $250.00 from Resident #1 and delayed repayment. The incident was reported to the Alabama Department of Public Health (ADPH) and resolved with repayment and termination of CNA #1.

The facility failed to ensure Resident #1 was free from misappropriation of funds when CNA #1 borrowed $250.00 from the resident against facility policy. The CNA was terminated, the loan was repaid, and corrective actions including staff education and resident council discussions were implemented.

The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), inadequate assistance with activities of daily living (nail care), improper oxygen administration, and failure to implement infection prevention and control practices properly during medication administration.

The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs (call light accessibility), inadequate assistance with activities of daily living (nail care), improper oxygen administration at prescribed rates, and multiple breaches in infection prevention and control practices including improper hand hygiene, glove use, and medication administration techniques.

The facility was found deficient in multiple areas including improper feeding practices compromising resident dignity, menu discrepancies affecting nutritional adequacy for many residents, failure to prevent cross-contamination in dishwashing procedures, and inadequate hand hygiene by staff during meal delivery, all posing minimal harm or potential for harm to residents.

The facility was found deficient in multiple areas including failure to ensure staff dignity during feeding, menu discrepancies affecting nutritional adequacy for many residents, improper hand hygiene practices leading to potential cross contamination in the kitchen, and failure of a CNA to sanitize hands during meal delivery affecting a few residents.

The complaint investigation found that Resident #69's responsible party was not notified of a new medication order for Lasix, and Resident #419's vital signs were not documented for three nights despite being taken. Both issues were substantiated based on interviews and record reviews.

The facility failed to notify the responsible party of Resident #69's new Lasix medication order and failed to document vital signs for Resident #419 as required by facility policy. These deficiencies were confirmed through interviews, record reviews, and policy examination.

The complaint investigation found that the facility did not notify Resident #69's responsible party about a new medication order for Lasix and did not document vital signs for Resident #419 as required. The deficiencies affected a few residents and one resident respectively.

The facility failed to notify the responsible party of Resident #69's new Lasix medication order and failed to document vital signs for Resident #419 as required by facility policy. These deficiencies were confirmed through interviews, record reviews, and policy examination.