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 Northway Health And Rehabilitation, Llc during CMS and state inspections, most recent first.
The facility did not maintain rooms on three out of five halls in a safe, clean, comfortable, and homelike environment, as required by residents' rights. Observations revealed issues such as missing closet doors, scraped and chipped paint, holes in walls, stained ceiling tiles, and maintenance problems with toilets. The Maintenance Director acknowledged these conditions and confirmed the need for repairs. Residents affected by these deficiencies included RI #56, RI #100, RI #67, RI #18, RI #9, RI #103, and RI #35.
Staff did not adhere to hand hygiene protocols while passing meal trays and assisting residents, leading to potential cross-contamination risks. Observations revealed that hand sanitization was not performed between these tasks, as required by facility policy. CNAs confirmed the lack of compliance, raising concerns about bacterial spread due to this oversight. Additionally, staff were seen assisting multiple residents without performing hand hygiene between interactions.
The facility failed to ensure residents had access to personal funds after business hours and on weekends, affecting multiple residents. The Resident Handbook stated no withdrawals could be made after business hours or on weekends, and residents were advised to withdraw funds on Fridays. Interviews confirmed the issue, and staff acknowledged the difficulty in managing withdrawals outside business hours.
An LPN misappropriated a resident's medications, specifically Percocet and Lyrica, by signing them out as administered but transferring them into a personal pill bottle. The resident reported not receiving the medications, and an investigation confirmed the misappropriation through camera footage and interviews with nursing staff.
The facility failed to ensure a resident's PASRR was accurately marked with a diagnosis of Bipolar Disorder, necessitating a Level II screening. The oversight was identified during a review, revealing that no diagnoses were selected on the screening form despite the resident's admission with Bipolar Disorder.
A resident with diagnoses of Pain and Neuropathy did not receive scheduled doses of Lyrica and Percocet, despite LPN documentation indicating otherwise. Interviews with staff and the resident confirmed the medications were not administered, violating facility policy.
The facility failed to deliver mail to residents on Saturdays, as required by their policy. Mail delivered on Saturdays was placed in the Activity Director's box and distributed on Monday, affecting 13 residents and potentially all residents in the facility. The DON acknowledged the importance of timely mail delivery.
Maintenance Deficiencies Impacting Resident Room Conditions
Penalty
Summary
The facility failed to ensure that rooms on three out of five halls were maintained in a safe, clean, comfortable, and homelike environment, as required by residents' rights. Observations on various dates revealed multiple issues in residents' rooms, including missing closet doors, scraped and chipped paint on walls, holes in walls, stained ceiling tiles, and maintenance issues with toilets. The Maintenance Director acknowledged during an interview that these conditions were not acceptable and required repair. Residents identified in the report, such as RI #56, RI #100, RI #67, RI #18, RI #9, RI #103, and RI #35, were directly impacted by the deficient maintenance of their rooms. The Maintenance Director confirmed the presence of the observed deficiencies, indicating a lack of proper upkeep in these areas. The report highlights a failure to uphold residents' rights to a safe and comfortable living environment within the facility.
Hand Hygiene Non-Compliance During Meal Service and Resident Assistance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices among staff during meal tray passing and resident assistance, leading to potential cross-contamination risks. Observations on 04/14/2024 revealed instances where staff did not sanitize their hands between passing meal trays, as required by facility policy. Interviews with CNAs confirmed the lack of hand hygiene compliance, with concerns raised about the spread of bacteria due to this oversight. Additionally, staff were observed assisting two residents simultaneously without performing hand hygiene, further increasing the risk of cross-contamination.
Lack of Access to Personal Funds After Business Hours and Weekends
Penalty
Summary
The facility failed to ensure residents had reasonable access to personal funds/petty cash after business hours and on weekends. This deficiency affected multiple residents, including those who attended a Resident Council Group meeting and reported their inability to access funds on weekends. The facility's Resident Handbook explicitly stated that no personal account withdrawals could be made after business hours or on weekends, and residents were advised to anticipate their cash needs and withdraw funds on Fridays before the business office closed. Interviews with residents and staff confirmed that residents were unable to access their funds outside of business hours, and the Financial Specialist Assistant acknowledged the difficulty in managing checks and balances for withdrawals outside of business hours. Several residents with varying cognitive abilities, as indicated by their Brief Interview for Mental Status (BIMS) scores, reported their inability to access funds on weekends. For instance, one resident mentioned using personal funds for snacks from vending machines and being unable to purchase snacks if they did not withdraw cash on Friday. The Financial Specialist confirmed that petty cash funds were locked up on the nurses' cart and that residents were initially informed they could obtain personal funds through the business office during the week. The Financial Specialist emphasized the importance of residents having access to their funds at all times, acknowledging that it was their money to use as they desired.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to ensure that an LPN did not misappropriate a resident's medications, specifically Percocet and Lyrica. The incident was discovered when the resident reported not receiving their pain medication during the 3 PM to 11 PM shift. The facility's investigation, which included a review of the electronic medical record and camera footage, revealed that the LPN had signed out the medications as administered but was seen transferring the medications into a personal pill bottle and then into her purse. This misappropriation was confirmed by the resident's consistent reports to multiple nurses that they had not received their pain medication, despite it being signed out as given by the LPN. The resident involved had been admitted to the facility with diagnoses of pain and neuropathy and had physician orders for Lyrica and Percocet. The controlled drug record indicated that the medications were signed out by the LPN on the evening in question. Interviews with the resident and other nursing staff corroborated the resident's claim of not receiving the medications. The Director of Nursing and the Administrator conducted an investigation, which included reviewing camera footage that showed the LPN taking the medications and not administering them to the resident. The facility determined that the LPN's actions constituted misappropriation of resident property, as the medications were signed out as administered but were not given to the resident. The LPN was terminated after the investigation confirmed the misappropriation. The incident highlighted the need for strict adherence to medication administration protocols to protect residents from such actions.
Failure to Accurately Complete PASRR for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that Resident Identifier (RI) #103's PASRR (Preadmission Screening and Resident Review) was accurately marked with an admission diagnosis of Bipolar Disorder, which indicated a Level II screening was necessary. The PASRR review, signed on 09/15/2023, did not indicate the resident had a Major Mental Illness of Bipolar Disorder, resulting in only a Level I screening being completed. This oversight was identified during a review on 04/15/2024, where it was found that no diagnoses were selected or marked on the screening form, despite the resident being admitted with a diagnosis of Bipolar Disorder on 10/27/2023. During an interview with Social Services staff, it was revealed that the facility's process for identifying residents needing a Level I or Level II screening involved reviewing diagnoses and medications, marking them on the screening form, and submitting it to the screening office. The Social Services staff confirmed that Bipolar Disorder should have been marked on the PASRR and acknowledged that the PASRR was inaccurate due to this omission. The staff member also stated that Social Services was responsible for ensuring the PASRR was accurate if a resident was admitted from another facility, and the failure to update the PASRR to include Bipolar Disorder resulted in an inaccurate diagnosis record.
Failure to Administer and Accurately Document Medication
Penalty
Summary
The facility failed to ensure the accuracy of Resident Identifier (RI) #43's Medication Administration Record (MAR). On 08/27/2023, Licensed Practical Nurse (LPN) #6 documented the administration of Lyrica and Percocet in RI #43's medical record without actually administering the medications. This discrepancy was confirmed through interviews with RI #43, who reported not receiving the medication, and with other staff members, including Registered Nurse (RN) #4 and LPN #5, who corroborated the resident's claim. The Director of Nursing (DON) and the Regional Nurse also confirmed that the medications were falsely documented as administered by LPN #6. RI #43 was admitted to the facility with diagnoses of Pain and Neuropathy and had physician orders for Lyrica and Percocet. The incident was brought to light when RI #43 informed LPN #5 that the pain medication was not administered as scheduled. Subsequent interviews with the Former Administrator and the DON revealed that LPN #6 had indeed falsified the records by signing out the medications without administering them. This action was in direct violation of the facility's policy on Medication Administration Documentation, which requires that the individual administering the medication records it immediately after administration.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required by their policy titled 'Federal Rights of Resident/Guest(s)'. During a Resident Council Meeting, 13 residents reported that mail delivered to the facility on Saturdays was not distributed to them until the following Monday. The Social Services Director confirmed that mail delivered on Saturdays was placed in the Activity Director's box and distributed on Monday. The Activity Director, who worked only Monday through Friday, corroborated this practice, stating that no staff delivered mail to residents on weekends. The Director of Nursing acknowledged that residents should receive their mail on Saturdays, as it is their personal mail and should be delivered in a timely manner. The DON also noted that failing to deliver mail on Saturdays could result in residents missing important communications from family or other significant information. This deficiency affected 13 residents who attended the Resident Council Meeting and had the potential to affect all residents in the facility.
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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) |
|---|---|---|---|---|
| Civic Center Health And Rehabilitation, Llc | 0.4 mi | ★★★★★ | 0 | 0 |
| Greenbriar At The Altamont Skilled Nursing Facilit | 2.5 mi | ★★★★★ | 0 | 0 |
| South Health And Rehabilitation, Llc | 2.6 mi | ★★★★★ | 0 | 0 |
| Oak Knoll Health And Rehabilitation, Llc | 2.8 mi | ★★★★★ | 0 | 0 |
| Arlington Rehabilitation & Healthcare Center | 3.5 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.