Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale University Park Snf (al) during CMS and state inspections, most recent first.
The facility failed to properly dispose of garbage, with two open dumpsters lacking lids and surrounded by scattered trash, attracting flies. The DES noted the increased use of these dumpsters due to a broken compactor. Additionally, an open bin of soiled linen with food and a discarded glove was found outside the laundry area, further indicating improper waste management.
The facility failed to ensure proper infection control in the laundry area, with issues such as a dirty sink, non-functional soap dispenser, and staff not wearing protective gear or practicing hand hygiene. Clean and dirty laundry were not separated, and soiled items were stored uncovered outside. The presence of flies and improper storage of cleaning equipment further contributed to potential contamination.
A facility failed to reconcile controlled medication records, leading to a missing Lorazepam card for a resident. The medication was not removed from the cart after being discontinued, and staff did not follow proper procedures during a shift change, resulting in the medication's loss.
A resident missed wound treatments for three consecutive days, and the facility failed to notify the MD or NP as required. The resident's Treatment Administration Record showed incomplete documentation, and interviews revealed a lack of communication regarding the missed and refused treatments. Despite the facility's policy on notifying physicians of treatment refusals, the MD and NP were not informed until after the resident's discharge.
A resident's Lorazepam medication was misappropriated when an LPN and an RN failed to count controlled medications during a shift change. The LPN handed over the medication cart keys to the RN without conducting a proper count, leading to the disappearance of two tablets. The incident was reported to the DCS, Nursing Home Administrator, and local authorities, and the missing medication was classified as misappropriation of resident property.
A resident did not receive daily surgical wound treatment as ordered by the physician over three days. Nursing staff failed to document and complete the treatment, with one nurse not returning to complete it, another not notifying medical staff of a refusal, and a third not performing the treatment before discharge. The facility's investigation confirmed the lapse in care.
A resident received Lorazepam without a physician's order after the medication was discontinued. The facility's policy requires psychotropic medications to be administered with appropriate orders, but doses were given on three occasions without adherence to these guidelines. The resident was unaware of the medication error, and the facility acknowledged the mistake, noting potential risks of increased falls or lethargy.
A resident was administered Lorazepam without an active physician's order on three occasions after the medication was discontinued. The facility's policy defines this as a medication error. Interviews revealed that the medication was not re-ordered upon the resident's return from the hospital, and staff failed to verify orders before administration. The error was identified during a complaint investigation, affecting one of five residents reviewed.
Improper Garbage Disposal and Pest Attraction
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. Two garbage dumpsters were found without lids, filled with trash and cardboard, and surrounded by scattered trash on the ground. This situation attracted numerous flies, indicating a potential pest problem. The Director of Environmental Services (DES) explained that the trash compactor had been removed due to malfunction, leading to increased use of the open dumpsters and possibly contributing to the fly activity. Additionally, an open bin of soiled linen was observed outside the laundry area, with food, a discarded glove, and flies present, further indicating improper waste management. Interviews with facility staff, including the DES, Housekeeping Supervisor, and Maintenance Director, confirmed that the open dumpsters were originally intended for remodeling debris but were being used for food waste due to the broken compactor. The staff acknowledged that the dumpsters lacked lids, making it impossible to close them, and that trash and food should not be left on the ground to prevent contamination and pest issues. The facility's policy on food-related garbage and refuse disposal was not adhered to, as the dumpsters were not kept closed, and the surrounding area was not maintained free of litter and pests.
Infection Control Deficiencies in Laundry Area
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures in the laundry area, as observed during a survey. The deficiencies included a dirty handwashing sink and a non-functional soap dispenser in the linen laundry room. Laundry staff were seen folding clean linens without wearing protective gear and did not wash or sanitize their hands after moving between the dirty and clean sides of the laundry room. Additionally, staff handled soiled linen from the trash can and then clean linens without performing hand hygiene. The facility also lacked a designated separate area for clean and dirty items in the laundry room, and dirty clothes and linen were stored outside uncovered. Interviews with the Director of Environmental Services and the Housekeeping Supervisor revealed that the facility's limited space contributed to the inability to separate clean and dirty laundry. The presence of flies in the laundry area was noted, and the DES acknowledged that this could lead to contamination. The HS admitted that a mop head and steam cleaner were improperly stored in the laundry area, posing a risk of contamination. The DES emphasized the importance of hand hygiene and wearing protective gear to prevent cross-contamination and the spread of infection.
Controlled Medication Mismanagement
Penalty
Summary
The facility failed to accurately account for and periodically reconcile controlled medication records, specifically for a resident's Lorazepam prescription. The deficiency was identified during an investigation following a complaint about the misappropriation of resident property. The investigation revealed that a card containing two tablets of Lorazepam was missing from the medication cart, and the controlled medication record for the resident was incomplete. The facility's policy required an accounting of all controlled drugs each shift by licensed nurses, but this was not adhered to in this instance. The incident involved a resident who had been prescribed Lorazepam for anxiety, which was later discontinued. However, the medication was not removed from the medication cart as required. During a shift change, a discrepancy in the narcotic count was noted, and it was discovered that the card of Lorazepam was missing. Interviews with staff revealed that the medication cart keys were handed over without a proper count of the controlled medications, leading to the loss of the medication card. The investigation involved multiple staff members, including LPNs and the Director of Clinical Services, who confirmed the missing medication. The facility's policy on controlled substances was not followed, as the discontinued medication was not removed from the cart, and the exchange of cart keys was not properly managed. This oversight had the potential to affect the resident involved and highlighted a lapse in the facility's medication management procedures.
Removal Plan
- Resident #12's discontinued medication was removed from the med cart.
- The facility notified ADPH, the Ombudsman, and local law enforcement.
- Impromptu QAPI completed with Medical Director, Director of Clinical Services, Nursing Home Administrator and Assistant Director of Clinical Services in attendance.
- Director of Clinical Services conducted audit of all carts for discontinued medications. No further incidents were identified.
- A third party pharmacy consultant completed a controlled substance MAR to cart audit. No additional concerns identified.
- The Director of Clinical Services or designee educated nurses on removal of discontinued medications from medication cart, types of medication errors to include wrong dose, route, form, drug, time, unauthorized drug, and dual documenting controlled medication administration on the Electronic Medication Administration Record and the Narcotic sheet, and all signatures must be readable.
- The Director of Clinical Services or designee started running the order listing report to include discontinued medications to assist with removal of discontinued controlled substances from the medication carts. The discontinued controlled substances are destroyed using the pharmaceutical destruction process.
- Director of Clinical Services or designee will conduct audit on medication cart for MAR to cart reconciliation 3 times a week for 30 days and re-assess as needed for compliance. Director of Clinical Services or designee will report findings to QAPI Committee monthly.
Failure to Notify MD/NP of Missed Wound Treatments
Penalty
Summary
The facility failed to ensure that licensed staff notified the Medical Doctor (MD) or Nurse Practitioner (NP) when a resident refused or missed wound treatment on three consecutive days. The resident, who was admitted for surgical aftercare following surgery on the skin and subcutaneous tissue, had orders for daily wound care that were not followed. On the first day, the treatment was not completed, and on the second day, the resident refused the treatment, but the refusal was not communicated to the MD, NP, or the oncoming nurse. On the third day, the resident was discharged before the treatment could be completed, and again, no notification was made to the MD or NP. The Treatment Administration Record (TAR) for the resident showed that the wound treatment was not documented as completed on the first day, marked as refused on the second day, and not completed on the third day. Interviews with the nursing staff revealed that the treatments were not performed as ordered, and there was a lack of communication regarding the missed and refused treatments. The Director of Clinical Services confirmed that the investigation revealed the wound care had not been completed for three days, and the MD should have been notified of the refusal and missed treatments. The Nurse Practitioner was informed about the missed treatments only after the resident had been discharged, which was not in line with the facility's policy that required immediate notification of the MD or NP for missed or refused treatments. The facility's policy on Resident Medication Rights emphasized the importance of notifying the physician or prescriber of a resident's refusal of treatment, especially if it could affect the resident's health or safety. Despite the failure to follow these procedures, the missed treatments did not result in harm to the resident.
Misappropriation of Resident's Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their controlled medication, specifically two tablets of Lorazepam, which were found missing. The incident occurred when a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) did not follow proper procedures for counting controlled medications during a shift change. The LPN handed over the keys to the medication cart to the RN without conducting a medication count, leading to the disappearance of the medication. The resident involved had a documented order for Lorazepam to manage anxiety, and their cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The medication record showed that five tablets were initially received, and three had been administered, leaving two tablets unaccounted for. The discrepancy was discovered during a routine narcotic count, and the missing medication was reported to the Director of Clinical Services (DCS), the Nursing Home Administrator, and local authorities. Interviews with the involved staff revealed that the LPN had left the medication cart keys with the RN without ensuring a proper count of the controlled substances. The facility's investigation confirmed that the medication card was missing and could not be located, classifying the incident as misappropriation of resident property. The resident expressed feelings of being robbed upon learning about the missing medication, although they did not recall receiving Lorazepam.
Failure to Administer Daily Wound Care
Penalty
Summary
The facility failed to ensure that a resident received daily surgical wound treatment as per the physician's orders. The resident, who was admitted for surgical aftercare following surgery on the skin and subcutaneous tissue, did not receive the prescribed wound care on three consecutive days. Specifically, the treatment was not documented or completed on the first day, was refused by the resident on the second day without proper notification to medical staff, and was not completed on the third day prior to the resident's discharge. Interviews with the nursing staff revealed lapses in following the wound care procedure. One nurse admitted to not completing the treatment after intending to return to it, while another nurse documented the resident's refusal but failed to inform the medical team or incoming nurse. The third nurse acknowledged that the treatment was not completed before the resident's discharge, despite recognizing that it should have been done. The facility's investigation confirmed that the wound care was not provided for three days, as reported by a family member. The investigation highlighted that the physician's orders were not followed, and the necessary wound care was not administered, although it did not result in harm to the resident.
Unauthorized Administration of Lorazepam
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic medication, Lorazepam, without a physician's order. The resident had orders for Lorazepam that were discontinued, yet doses were administered on three separate occasions after the discontinuation. The medication was given on 05/25/2024, 05/28/2024, and 05/30/2024, despite the orders being discontinued on 05/22/2024. The facility's policy on psychotropic drug management requires that medications be initiated at the lowest effective dose and include appropriate diagnosis, drug dose, frequency, and monitoring parameters. However, the administration of Lorazepam to the resident occurred without adherence to these guidelines, as the medication was given without a valid order. Interviews with the Director of Clinical Services and the Administrator confirmed that the medication was administered after being discontinued, which was against the facility's policy. The resident, who had intact cognition as indicated by a BIMS score of 14 out of 15, was unaware of the medications prescribed or received. The facility identified that the medication was administered after being discontinued and acknowledged the error. The Director of Clinical Services noted that administering the medication after discontinuation could have increased the risk of falls or lethargy, although no harm was reported for the resident.
Resident Administered Lorazepam Without Active Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff administered Lorazepam without an active physician's order. The resident, identified as having intact cognition, had their Lorazepam orders discontinued on a specific date. Despite this, doses of Lorazepam were administered on three separate occasions after the discontinuation date, as documented in the Controlled Drug Record and Narcotic Log. The signatures of the nurses who administered the medication were not readable. Interviews with the Director of Clinical Services and the Administrator revealed that the medication was administered after being discontinued, which could have increased the risk of falls or lethargy for the resident. The Administrator confirmed that the Lorazepam was not re-ordered upon the resident's return from the hospital, and the medication cards were not removed from the medication cart. The staff failed to verify the orders in the computer before administering the medication. The deficiency was identified during an investigation of a complaint, affecting one of five residents reviewed for medication administration. The facility's policy on medication errors clearly states that administering a drug without a physician's order constitutes a medication error. The facility acknowledged the error and noted that the resident did not suffer any harm as a result of the medication being administered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Birmingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elite Nursing And Rehabilitation Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| South Health And Rehabilitation, Llc | 2.7 mi | ★★★★★ | 0 | 0 |
| Greenbriar At The Altamont Skilled Nursing Facilit | 3.4 mi | ★★★★★ | 0 | 0 |
| Aspire Physical Recovery Center At Hoover, Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| South Haven Health And Rehabilitation, Llc | 3.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.