Birmingham Nursing and Rehabilitation CTR LLC

In the surveyor’s words

From the most serious findings on record at Birmingham Nursing and Rehabilitation CTR LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF656May 3, 2022

  Based on observations, interviews, resident record reviews, and review of facility policies titled SUBJECT: SMOKING and COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure: A) the information obtained through the facility's Smoking Safety Evaluations was utilized in a manner to allow staff to develop and implement person-centered safety interventions for Resident Identifier (RI) #s 177, 10, 82, 48, 58, and 59. These six of six sampled residents reviewed for smoking safety have documented episodes of noncompliance with the facility's Smoking Policy, including smoking inside the facility unsupervised in resident rooms and/or bathroom areas. […]

• Immediate jeopardy, widespreadF689May 3, 2022

  Based on observation, record review, interviews, review of the facility's investigative file related to a fire involving Resident Identifier (RI) #177, and review of the facility's policy titled SUBJECT: SMOKING, the facility failed to accurately and completely conduct SMOKING SAFETY EVALUATION(s) in accordance with facility policy. Further, the facility failed to ensure the information obtained through the SMOKING SAFETY EVALUATION(s) was utilized in a manner to allow staff to develop, implement and revise person-centered safety interventions for RI #s 177, 10, 82, 48, 58, and 59, six of six sampled residents reviewed for smoking safety. […]

• Immediate jeopardy, widespreadF740May 3, 2022

  Based on record review, interviews, review of the Social Worker (SW) Job Description, and review of a facility policy titled, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, the facility failed to ensure Resident Identifier (RI) #s 177, 10, 48, 82, 58, and 59 were placed on a behavior management program. RI #s 177, 10, 48, 82, 58, and 59 were all found to have Nurses' Notes describing unsafe behaviors related to noncompliance with the facility's Smoking Policy. Despite, Social Service involvement in resident evaluations and reviews, Social Services was unaware of resident's behaviors, due to staff failing to notify them of the behaviors. […]

• Immediate jeopardy, widespreadF835May 3, 2022

  Based on interviews, review of the facility's QAPI (Quality Assurance Process Improvement) Plan and review of the facility Administrator's job description, facility administration failed to ensure staff were consistently implementing the facility's smoking policy. Further, the Administrator admitted prior knowledge of resident noncompliance with the facility's smoking policy, but failed to present the incidents to the facility's Quality Assurance (QA) Committee for review/investigation in order to identify systemic breakdowns, so that actions could be taken to ensure facility systems did not contribute to further noncompliance with the facility's smoking policy. […]

• Immediate jeopardy, widespreadF837May 3, 2022

  Based on interview and review of Employee Identifier (EI) #2's (Vice President of the facility's management company and member of the governing body) job description, the governing body failed to provide oversight to facility staff to ensure appropriate actions were taken following a fire on 03/26/2022 in which Resident Identifier (RI) #177 ignited his/her bedding and body while smoking in bed. While an investigation was done at the facility level, the facility failed to review and consider all pertinent resident records and facility systems related to resident smoking policies. As a result, the facility did not identify all actions and/or systemic changes needed to prevent any further injuries to residents as a result of smoking noncompliance and fire hazards. […]