Highlands Rehabilitation and Wellness Center
Birmingham, Alabama · CCN 015134
18 surveys since 2012, 7 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 69
- Surveys
- 18
- Harm or worse
- 7
- Immediate jeopardy
- 5
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 132
- Ownership
- For profit - Limited Liability company
- Chain
- LEGACY HEALTHCARE
- County
- Jefferson
- Medicare-certified since
- 1976
CMS ratings
- Overall
- 2
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=14, floor 20).
Last survey on record
May 13, 2024
910 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 2.87 | 3.81 |
| Registered-nurse hours per resident day | 0.37 | — |
| Annual nurse turnover | 55.7% | 47.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $24,834 across 5 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J428.6% | K— | L17.1% |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D642.9% | E— | F17.1% |
| No harm, potential for minimal | A— | B— | C214.3% |
In the surveyor’s words
From the most serious findings on record at Highlands Rehabilitation and Wellness Center, in the surveyor’s own words.
- Immediate jeopardy, widespreadF867May 13, 2024
Based on interviews, record review, and review of facility policies titled Quality Improvement Program, and Quality Assurance Performance Improvement Plan the facility's Quality Assurance Performance Improvement (QAPI) committee failed to systemically address all causal factors related to four staff providing Cardiopulmonary Resuscitation (CPR) to Resident Identifier (RI) #159, a resident with Advanced Directive for Do Not Resuscitate (DNR). The QAPI committee further failed to notify the Governing Body of the adverse event. On [DATE] RI #159's end-of-life wishes were not honored. Licensed staff failed to review RI #159's chart for code status prior to CPR. RI #159's nurse was not in the facility at the time of the code but was sitting outside in the car. […]
- Immediate jeopardy, isolatedF578May 13, 2024
Based on interviews, medical record review, FUNDAMENTALS OF NURSING NINTH EDITION, a complaint received by the Alabama Department of Public Health, the facility's policies titled RESIDENT BILL OF RIGHTS, ADVANCE DIRECTIVES, and Cardio Pulmonary Resuscitation (CPR), the facility failed to honor Resident Identifier (RI) #159's Advanced Directive for end-of-life wishes. RI #159 had an Advanced Directive which directed staff to withhold resuscitative measures in the event of cardiopulmonary cessation and an active physician's order for DNR (Do Not Resuscitate) code status. During the evening shift on [DATE], RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8 around 8:20 PM. […]
- Immediate jeopardy, isolatedF678May 13, 2024
Based on record review, interviews, a complaint recieved by the Alabama Department of Public Health, and the facility policy titled Cardio Pulmonary Resuscitation (CPR) the facility failed to ensure CPR was not initiated for Resident Identifier (RI) #159 on [DATE]. RI #159 had an Advanced Directive directing staff to withhold lifesaving measures including CPR. On [DATE] at approximately 8:20 PM, RI #159 was found by Certified Nursing Assistant (CNA) #8 in respiratory distress, mumbling and appeared pale in color. CNA #8, notified Registered Nurse (RN) #9 who responded and found RI #159 to be unresponsive to sternal rub. RN #9 initiated CPR and instructed CNA #8 to call a Code Blue and summon additional assistance from facility staff. […]
- Immediate jeopardy, isolatedF725May 13, 2024
Based on record review and interviews, the facility failed to provide sufficient nursing staff to consistently meet the needs of the residents. This deficient practice affected Resident Identifier (RI) #159. The facility failed to ensure the South Unit was properly staffed on [DATE] around 8:20 PM when RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. Two nurses were scheduled to be working on the unit; however, one nurse left early after working nearly 15 hours that day and the other one was in the parking lot. […]
- Immediate jeopardy, isolatedF726May 13, 2024
Based on record review, interview, a facility document titled Code Blue Evaluation, and the facility CARDIOPULMONARY RESUSCITATION (CPR), the facility failed to ensure the facility provided training and skills verification to staff on their CPR policy. The facility did not implement training and skills verification to ensure all staff were able to respond to an emergent situation according to their policy to verify a resident's code status before initiating CPR. On [DATE] around 8:20 PM RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. The staff who responded initiated CPR without first verifying Resident Identifier (RI) #159's code status in the medical record. […]
Read 22 findings in full →The most serious and the most recent: 22 of 69 on record.
Every survey on record
FindingsAt actual harm or above
- May 13, 2024Standard and complaint11 findings · 5 harm
- Jun 3, 2022Infection control1 finding
- Apr 20, 2021Standard and complaint2 findings
- Oct 1, 2020Complaint1 finding
- Mar 13, 2019Standard3 findings
- Apr 19, 2018Standard4 findings
- Jul 20, 2017Complaint3 findings
- Mar 23, 2017Standard7 findings
Show the 10 earlier surveys
- Aug 11, 2016Complaint4 findings
- Feb 24, 2016Standard6 findings
- May 29, 2015Complaint1 finding
- Jan 15, 2015Standard2 findings
- Jul 3, 2014Complaint2 findings · 2 harm
- May 22, 2014Complaint2 findings
- Mar 13, 2014Standard6 findings
- Jan 4, 2013—5 findings
- Jul 19, 2012—3 findings
- Feb 16, 2012—6 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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