General Information: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Nursing home name HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Address39 HANOVER CIRCLE S
BIRMINGHAM, AL 35205
Phone number (205) 933-1828
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare
Continue Care Retirement CommunityNo
Resident and family councils RESIDENT
Certified number of beds 66
Total number of residents 21
Perc of occupied beds 32
Sprinkler status Yes
Last health survey date 10/25/2012
Fire survey date: 10/25/2012
Ratings Summary: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Overall rating 4
4
Nursing Home Staffing 4
4
Registered Nurses only 4
4
Health Inspections 3
3
Quality Measures 4
4
Nursing Home Staffing Info: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
National AverageHANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Overall staff rating Not Available. 4
4
Registered Nurses only rating Not Available 4
4
Total Number of Residents 88.1 21.00
Total Number of Licensed Nurse Staff Hours per Resident per Day 29.8 hours 3.15 hours
Registered Nurses Hours per Residents per Day 29.0 hours 1.51 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 29.0 hours 1.63 hours
Certified Nursing Assistants Hours per Residents per Day 29.0 hours 1.51 hours
Health Inpections: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Inspection Results: 10/25/2012
CorrectedCategoryDeficiencySeverity
11/23/2012Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. D
11/23/2012Environmental DeficienciesHave a program that investigates, controls and keeps infection from spreading. D
11/23/2012Resident Assessment DeficienciesMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. E
11/23/2012Quality Care DeficienciesEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. D
11/23/2012Resident Rights DeficienciesKeep residents' personal and medical records private and confidential. D
Inspection Results: 02/09/2012
CorrectedCategoryDeficiencySeverity
03/15/2012Pharmacy Service DeficienciesAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. D
Inspection Results: 03/03/2011
CorrectedCategoryDeficiencySeverity
04/07/2011Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. D
04/07/2011Pharmacy Service DeficienciesMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. E
04/07/2011Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. F
04/07/2011Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. D
04/07/2011Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. E

Fire Safety Inpections: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Inspection Results: 02/09/2012
CorrectedCategoryDeficiencySeverity
03/15/2012Automatic Sprinkler Systems DeficienciesAutomatic sprinkler systems that have been maintained in working order. E
03/15/2012Corridor Walls and Doors DeficienciesCorridor and hallway doors that block smoke. D
Inspection Results: 03/08/2011
CorrectedCategoryDeficiencySeverity
04/20/2011Electrical DeficienciesProperly installed electrical wiring and equipment. D
04/20/2011Automatic Sprinkler Systems DeficienciesAn approved automatic sprinkler system connected to the fire alarm system. E
04/20/2011Exits and Egress DeficienciesExits that are accessible at all times. E
04/20/2011Corridor Walls and Doors DeficienciesCorridor and hallway doors that block smoke. E

Resident Complaints: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Date Complaint Substantiated: 10/25/2012
CorrectedCategoryDeficiencySeverity
11/23/2012Environmental DeficienciesHave a program that investigates D
11/23/2012Quality Care DeficienciesEnsure that each resident who enters the nursing home without a catheter is not given a catheter D
11/23/2012Resident Rights DeficienciesKeep residents' personal and medical records private and confidential. D

Quality Measures: HANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Quality MeasuresNational AverageHANOVER HEALTH AND REHABILITATION AT BIRMINGHAM
Overall quality rating Not Available 4
4
Long-Stay Residents
Percent of long-stay residents who lose too much weight. 16% 199%
Percent of long-stay residents who have depressive symptoms. 16% 199%
Percent of long-stay residents who self-report moderate to severe pain. 22% 199%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine. 99% 199%
Percent of long-stay high-risk residents with pressure ulcers. 19% 199%
Percent of long-stay residents who were physically restrained. 11% 199%
Percent of long-stay residents who received an antipsychotic medication. 31% 199%
Percent of long-stay residents whose need for help with daily activities has increased. 27% 199%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 97% 199%
Percent of long-stay low-risk residents who lose control of their bowels or bladder 62% 199%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder. 13% 199%
Percent of long-stay residents with a urinary tract infection. 16% 199%
Percent of long-stay residents experiencing one or more falls with major injury. 12% 199%
Short-Stay Residents
Percent of short-stay residents who newly received an antipsychotic medication. 27% 2.2000000000000002%
Percent of short-stay residents who self-report moderate to severe pain. 36% 25.100000000000001%
Percent of short-stay residents with Pressure ulcers that are new or worsened. 11% 1.2%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 92% 88%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine. 87% 89.799999999999997%
Severity Codes Explanation. Note: The higher the letter, the higher the severity.
AIsolated /Potential for minimal harm
BPattern /Potential for minimal harm
CWidespread /Potential for minimal harm
DIsolated /Minimal harm or potential for actual harm
EPattern /Minimal harm or potential for actual harm
FWidespread /Minimal harm or potential for actual harm
GIsolated /Actual harm
HPattern /Actual harm
IWidespread /Actual harm
JIsolated /Immediate jeopardy to resident health or safety
KPattern /Immediate jeopardy to resident health or safety
LWidespread /Immediate jeopardy to resident health or safety

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