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Oaks On Parkwood Skilled Nursing Facility

2625 Laurel Oak Drive, Bessemer, AL 35022 · Non profit - Corporation · 130 certified beds · (205) 497-4520 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 2025Behavioral-health or dementia-care citation — no harm found (F0740)1 immediate-jeopardy citation$17,345 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,345 in federal fines (most recent 2025-09-28)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • its last standard health inspection was over 5 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
5657 Post Oak Trail · (205) 590-9406 · Call to confirm hours
Pharmacy
Grocery
8169 Dickey Springs Rd · (205) 425-6760 · Call to confirm hours
Park
601 2nd Ave N · (205) 425-0655 · Typically dawn to dusk
Place of worship
8100 Hopewell Rd SE · (205) 424-8100

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.3%12.0%15.4%better
Long-stay residents who lose too much weight5.3%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder1.3%1.0%0.9%worse
Long-stay residents with a urinary tract infection1.6%2.4%2.0%better
Long-stay residents with depressive symptoms1.7%1.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.6%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury8.3%3.3%3.3%worse
Long-stay residents whose ability to walk worsened14.2%12.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication28.9%24.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%94.8%95.3%typical
Long-stay residents with pressure ulcers3.4%5.4%4.7%better
Long-stay residents with worsening bladder/bowel control9.4%12.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table22.7%21.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.3%2.0%1.4%worse
Short-stay residents given the seasonal flu vaccine93.8%80.3%79.4%better
Short-stay residents rehospitalized after admission32.9%24.8%22.6%worse
Short-stay residents with an outpatient ER visit15.4%11.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.221.961.67worse
Long-stay outpatient ER visits per 1,000 resident days2.291.701.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

51.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.0%U.S. median 51.5%
Got home and stayed home
13.6%U.S. median 10.7%
Went back to hospital
47.8%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 47.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 46 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.0%CMS range 37.6–60.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.6%CMS range 9.8–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge58.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.5–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.73
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.61
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.60
RN hoursweekends
44.2%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 130 beds and averages 124.5 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 4.22 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.79 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2021-05-20)
6
at the previous standard inspection (2019-07-18)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 5 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record review, review of a third-party complaint received by the State Agency (SA), and review of the facility's investigative file the facility failed to ensure a process was developed and implemented to ensure the doors leading into the kitchen from the main dining room were locked when the kitchen staff were not present. On 05/18/2025, one of the two doors leading from the main dining room into the kitchen was not locked after dietary staff left for the evening. Resident Identifier (RI #141) entered the kitchen through the unlocked door, secured two knives and stabbed him/herself five times in the chest/abdomen area. A facility staff member heard RI #141 in the kitchen and responded. RI #141 was sent to the hospital and evaluated, RI #141 was found to have five self-inflicted stab wounds located to the right chest, epigastric and left upper quadrant area. RI #141 was taken to the operating room (OR) for exploratory laparotomy (a surgical procedure that involves opening the abdomen…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-28 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect, and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff and residents. The facility further failed to supervise combative, agitated residents and wandering residents in a manner to prevent abuse of residents.Specifically:1.) The facility failed to protect Resident Identifier (RI) #137 from verbal abuse perpetrated by Nurse Aide Trainee (NAT) #17. On 05/04/2024 Certified Nursing Assistant (CNA) #16 witnessed RI #137 curse at NAT #17, then NAT #17 responded by calling RI #137 a bitch. Because CNA #16 failed to report the verbal abuse immediately, NAT #17 continued working his assigned schedule on 05/04/2024, 05/05/2024, and 05/06/2024; leaving RI #137 and other residents at risk of abuse. The verbal abuse was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-28 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to implement the abuse policy to ensure residents were protected from further abuse when a Nurse Aide Trainee (NAT) #17 continued working in the facility on 05/05/2024 and 05/06/2024 after he was witnessed verbally abusing Resident Identifier (RI) #137 on 05/04/2024. Certified Nursing Assistant (CNA #16) who witnessed NAT #17 call RI #137 a bitch, failed to report the abuse to anyone until she was questioned about another allegation on 05/07/2024. The facility failed to determine when the verbal abuse had occurred. After surveyor review of timecards and assignments for CNA #16 and NAT #17 it was determined the only shift they worked together and the witnessed verbal abuse of RI #137 was on 05/04/2024.This deficient practice affected RI #137 and created the potential for residents to experience ongoing abuse and placed residents in the facility at risk. This deficient practice was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and a facility policy titled Abuse, Neglect, and Exploitation the facility failed to ensure Certified Nursing Assistant (CNA) #16 immediately reported verbal abuse she witnessed on 05/04/2024 when Nurse Aide Trainee (NAT) #17 called Resident Identifier (RI) #137 a bitch. This incident was discovered by the facility during their investigation into an allegation of physical abuse reported on 05/07/2024 affecting RI #137, one of eight residents sampled for abuse. This deficient practice was cited as a result of the investigation of complaint/intake number 468255.Findings Include: Cross-reference F600 and F607. On 05/07/2024 at 11:45 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse when Licensed Practical Nurse (LPN) #19 was informed by RI #137 that the night prior a male CNA came into his/her room and poked him/her on the forehead multiple times. A review of a policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-28 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, review of a facility policy titled Behavior Management Program, review of a Facility Reported Incident (FRI) received by the State Agency and review of a facility investigative file, the facility failed manage Resident Identifier (RI) #136's behaviors in a manner to reduce agitation and prevent escalation of behaviors for RI #136 on 09/15/2024 when Registered Nurse (RN) #27 and Certified Nursing Assistant (CNA) #37 provided Activity of Daily Living (ADL) care to RI #136, a resident with Dementia with Behavior Disturbance and a history of aggressive and paranoid behavior. RN #27 and CNA #37 failed to implement behavior approaches during ADL care to provide a calm environment, allow RI #136 time alone, promote independence and a sense of control, when RI #136 verbally and physically resisted ADL care.The facility further failed to continue monitoring and review of RI #136's documented behaviors in August and September 2024 leading up to 09/15/2024 and failed to update…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of a facility policy titled Medication, Oral/Sublingual Administration, review of a Facility Reported Incident (FRI) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #9, RI #10, RI #11, and RI #13 received their medications on the three to eleven (3-11) PM shift on 01/09/2023 as ordered by the physician. This deficient practice had the potential to affect four of four residents residing on the secured unit at the facility; which is one of three units at the facility. Findings include: Review of a facility policy titled Medication, Oral/Sublingual Administration, with an effective date of 05/2014, revealed the following: PURPOSE: To administer oral medications in an organized and safe manner. STANDARD: Medications are administered orally under the orders of the attending physician. The facility submitted an Online Incident Report to the Alabama Department of Public Health…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Potential for harm · F2021-05-20 · tag F0803 — failed to meet residents' dietary needs — widespread
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the facility's policies titled Food Preparation Principles and Menus, Cycle and Meal Schedule, and review of the facility's Diet Spreadsheet, the facility failed to ensure: 1.) the portion size for fruit juice as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at breakfast; 2.) the portion size for Scalloped Potatoes and for Pureed Scalloped Potatoes as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at lunch; and 3.) portion sizes were identified for Mixed Vegetables on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, for the lunch meal. This had the potential to affect 85 of 85 residents receiving meals from the kitchen. Findings include: During an interview with Resident Identifier (RI) #23 on 5/18/2021 at 11:42 AM, RI #23 reported the facility was serving smaller portion sizes for meals. During an interview with RI #31 on 5/18/2021 at 4:40 PM, RI #31 reported portion sizes for meals had decreased. A review of the facility's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-05-20 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and review of a facility policy titled Food Preparation Principles, the facility failed to ensure residents received hot foods at palatable temperatures. This had the potential to affect 85 of 85 residents receiving meals in the facility. Findings include: Review of a facility policy titled Food Preparation Principles, effective 6/2018, revealed the following: . STANDARD: . Food . should be served . at proper temperatures. On 5/18/2021 at 5:52 PM, the surveyor observed Resident Identifier (RI) #6's supper meal. RI #6 received a bowl of chicken noodle soup with the meal. As RI #6 began to eat the soup, he/she reported to the surveyor the soup was cold. RI #6 said, Please stick your finger in it. I am not going to eat it. You can see I am telling the truth. The surveyor told RI #6 she would not put her finger in the soup, however, RI #6 could spoon some of the soup into the surveyor's hand. RI #6 did so and the surveyor observed the soup to be cool to touch. On 5/19/2021 at 8:48 AM, the surveyor observed RI #24's breakfast meal. RI #24 received a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2019-07-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews with staff, and a review of the 2017 United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to consistently maintain the temperature of the final rinse water of the dish machine within recommended levels. This had the potential to affect all 122 residents for whom meals were prepared and served at the time of the survey. Based on observation, the facility also failed to consistently date and label food items, stored in the nursing unit refrigerators, that were provided to residents during activity. This affected one of three nursing unit refrigerators. Findings included: 1) DISHWASHING The 2017 United States Food and Drug Administration Food Code mandates under 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 194 degrees F . In reference to the above regulation, the Food Code Annex explains, .When the sanitizing rinse temperature exceeds 194 degrees F at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and a review of the Resident Centered Care Plan Meeting facility policy, the facility failed to ensure Resident Identifier (RI) #90 was invited to participate in his/her care plan meeting. This affected one of 22 sampled, in-house residents. Findings Include: The facility policy titled, . Resident Centered Care Plan Meeting with an effective date of 1/2018 included the following: .2.Resident centered care plan letters, emails and calls to responsible parties by SSD (Social Services Director) or designee should be done at least 2 weeks in advance. .4. The SSD or designee should set the tone of the meeting with the resident's representative and/or resident and advise them of the purpose of the meeting . .8. All IDCP (Interdisciplinary Care Plan) team members in attendance as well as the resident's representative and/or resident should sign the attendance form. RI #90 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. The resident's Brief Interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #2's Gender and Ethnicity was coded accurately on RI #2's admission Minimum Data Set (MDS) assessment dated [DATE]. This affected 1 of 26 sampled residents whose MDS' were reviewed. Findings Include: RI #2 was admitted to the facility on [DATE]. A review of RI #2's admission MDS assessment, with an Assessment Reference Date (ARD) of 03/28/19, coded RI #2 as being a Female under A0800 Gender. RI #2 was also checked as being Black or African American under A1000C Ethnicity. On 07/18/19 at 3:07 p.m., the surveyor asked RI#2 what was his/her race. RI #2 said white. On 07/18/19 at 3:28 p.m., the surveyor conducted an interview with Employee Identifier (EI) #10, a LPN (licensed Practical Nurse)/MDS Coordinator. The surveyor asked EI #10 what was the race of RI #2. EI #10 said the MDS says African American. When asked what race RI #1 was, EI #10 said she believed RI #2 was white. The surveyor asked EI #10 what was the issue…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · D2019-07-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of a facility policy titled Dressings, Clean (Wound Care), the facility failed to ensure Resident Identifier (RI) #81's dressing to his/her coccyx remained on the resident's coccyx at all times. This deficient practice affected RI #81, one of three residents observed for wound care. Findings Include: Review of a facility policy titled Dressing, Clean (Wound Care), with an effective date of 03/18, revealed the following: PURPOSE: To provide guidelines for the care of wounds . to decrease the potential for nosocomial infection . PROCESS: . 13. Dress wound . RI #81 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of Pressure Ulcer of Sacral Region, Stage 4. RI #81's July 2019 Physician Orders revealed: . APPLY CALCIUM ALGINATE WITH SILVER TO COCCYX THEN COVER WITH A DRY PROTECTIVE DRESSING DAILY ., order date 5/06/19. 07/17/19 at 10:53 a.m., the surveyor observed Employee Identifier (EI) #11, the treatment nurse gather…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews, the facility failed to ensure Employee Identifier(EI) #15 did not leave Resident Identifier (RI) #116's bottle of eye drops at the bedside during the medication administration pass observation on 07/18/19. This deficient practice affected RI #116, one of four residents observed during the medication administration pass. Findings Include: RI #116 was admitted to the facility on 11//30/16, with the diagnosis of Unspecified Glaucoma. On 07/18/19 at 10:35 a.m., the surveyor observed Employee Identifier (EI) #15 administer RI #116's Brimonidine 0.2% eye drops. After administering the eye drops, EI #15 left the eye drops on the bedside table. When asked where she left RI #116's eye drops, EI #15 said on RI #116's bedside table. The surveyor asked EI #15 were the eye drops out of her view site. EI #15 said yes. When asked what would be the issue with medications being out of the site of the nurse, EI #15 said if the resident was confused they could grab it or the medication could get misplaced. On 07/18/19 at 4:53 p.m., the surveyor conducted an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of a facility policy titled Isolation, Types of (Infection), the facility failed to ensure: 1) the treatment nurse, Employee Identifier (EI) #11, did not take take a bottle of Vashe Wound Cleanser (WC) into Resident Identifier (RI) #12's Isolation room, then bring the WC back out of the room and place it in the treatment cart on 07/17/19; and 2) a Certified Nursing Assistant (CNA), EI # 6, wore an isolation gown and gloves when entering RI #12's isolation room, to assist with care, on 07/17/19. These deficient practices occurred by EI #11 and EI #6, two of two staff who were observed to enter RI #12's isolation room to provide care to the resident. Findings Include: 1) RI #12 was admitted to the facility on [DATE], with a diagnosis of Enterocolitis due to Clostridium. RI #12's July 2019 Physician Orders revealed: . ISOLATION PRECAUTION FOR C-DIFF (Clostridium Difficile) date 4/29/19 . VASHE WOUND SOLUTION-CLEAN WOUND TO COCCYX . date 7/12/19. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2018-07-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and review of the facility's policy titled Hand Washing (Infection Control), the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) sanitized her hands after removing her gloves during medication administration observation on 7/18/2018. The deficient practice affected RI #7, RI #42, RI #78 and RI 81, four of six residents observed for medication administration. Findings include: The facility's policy titled Hand Washing (Infection Control), with an effective date of April 2018, documented PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with residents . During medication administration observation on 7/18/2018 at 8:22 AM, EI #5, a Licensed Practical Nurse (LPN) prepared medications for RI #7. After EI #5 performed handwashing, she placed gloves on then gave one squirt of Flonase to the resident's left then right nostril. EI #5 removed her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-07-19 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of Resident Identifier (RI) #8's medical record and the facility's policy titled Health Information/Medical Records, Employee Identifier (EI) #8, the Licensed Practical Nurse (LPN)/Treatment Nurse failed to close RI #8's treatment record when she entered the resident's room. EI #8 left the resident's treatment record open on the treatment care, with the resident's treatment orders visible for public view. This deficient practice affected RI #8, one of one sampled residents reviewed for privacy. Findings include: The facility's policy titled, Health Information/Medical Records with an effective date of March 2017, documented . All information related to the resident's care, treatment and medical condition is confidential . RI #8 was readmitted to the facility on [DATE] with an admit diagnosis of Pressure Ulcer of Sacral Region. During wound care observation performed by EI #8, the LPN/Treatment Nurse on 7/18/2018 at 2:17 PM, EI #8 left RI #8's treatment record open (for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-07-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of Resident Identifier (RI) #42's medical record and Fundamentals of Nursing, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) did not initial RI #42's Medication Administration Record (MAR) before she administered medication to the resident on 7/18/2018. This deficient practice affected RI #42, one of six residents observed for medication administration. Findings include: Chapter 32 titled Medication Administration, page 628 and 629 of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of 2017, documented . After administering a medication, immediately document which medication was given on a patient's MAR . Never document that you have given a medication until after you have actually given it . RI #42 was readmitted to the facility on [DATE]. RI #42's PHYSICIAN'S ORDERS for July 2018, documented . ATIVAN 0.5 MG TABLET . GIVE 1 TABLET BY MOUTH 3 TIMES A DAY AS NEEDED FOR ANXIETY . OXYCODONE HCL 5 MG TABLET GIVE 1 TABLET…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-07-19 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #8 and RI #71, both residents who required extensive assistance with toileting, was toileted as needed. During continuous observation of RI #8 on 7/18/2018 from 2:30 PM to 5:49 PM, RI #8 was not checked for incontinence. When the staff provided incontinence care RI #8 was moderately saturated with urine. This deficient practice affected RI #8, one of three sampled residents reviewed for incontinence. On 7/19/2018, RI #71 was observed to sit in a soiled adult brief for over a time span of three hours. This deficient practice affected RI #71, one of one resident observed who required assistance with toileting. Finding include: 1) RI #71 was admitted to the facility on [DATE]. RI #71's plan of care titled Resident has incontinence related to decreased mobility and impaired cognition, with a problem onset date of 9/18/2017, had an approach of *Assist with toileting as needed . RI #71's Quarterly Minimum Data…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2018-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and medical record review, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) did not leave a pair of scissors unattended on top of the medication cart during medication administration observation on 7/18/2018. This was observed on one of two days of medication administration observation. The facility further failed to ensure EI #8, a LPN did not leave the treatment cart unlocked when she entered RI #8's room and closed the door, leaving the treatment cart out of her sight on 7/18/2018. This deficient practice was observed during one of three sampled residents reviewed for pressure ulcers. Findings include: 1) During medication administration observation on 7/18/2018 at 9:31 AM, EI #5, a Licensed Practical Nurse (LPN) cut the top of a Lidocaine patch open. EI #5 left the scissors on top of the medication cart unattended when she entered RI #81's room to administer medications to the resident. At 9:46 AM, EI #5 returned to the medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-07-19 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of Resident Identifier (RI) #39's medical record, the facility's policy titled Guidelines Enteral Feeding and the manufacturer's recommendations for prefilled enteral feeding containers, the facility failed to ensure RI #39's tube feeding did not hang for greater than 48 hours. This deficient practice affected RI #39, one of one sampled residents reviewed for tube feeding. Finding include: The facility's policy titled, Guidelines Enteral Feeding with an effective date of January 2018, documented . Other considerations related to Enteral Feeding . Enteral feedings ready to hang containers . Closed system enteral feedings can safely hang for up to 48 hours using clean technique . The manufacturer's instructions for Jevity documented . prefilled Enteral Feeding Containers can safely hang up to 48 hours . RI #39 was admitted to the facility on [DATE]. RI #39 has a medical history to include: Gastrostomy, Dysphagia and Adult Failure to Thrive. RI #39's Quarterly Minimum Data…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$17,345 in federal fines across 1 penalty.

  • $17,345 — penalty dated 2025-09-28

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NOLAND HEALTH — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.7-1.7 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 5 of 54.1+0.9 vs chain
Quality measures 1 of 53.0-2.0 vs chain
The other 9 homes this chain runs (chain average 2.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
ADAMSON, MICHELEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/10/2017
BASS, DONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/13/2023
BRITTON, ISAACIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2009
ESTEP, BARBARAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
GOFF, ROBERTIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 04/01/2009
HALL, MATTHEWIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/31/2022
NELSON, DEBRAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/11/2017
RENDA, NICHOLASIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/26/2020
SMITH, GEORGEIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 02/07/2014
THOMAS, ADEEBIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 02/01/2018
WAGGONER, JAMESIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTORsince 05/10/2017
NOLAND HEALTH SERVICES, INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2009
BLACKWELL, CRYSTALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/09/2025
COLLIER, COURTNEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/22/2023
KENWRIGHT, KARENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/27/2017
SMOTHERS, KATHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/12/2021
URBAN, KELLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2019
MORRISON MANAGEMENT SPECIALISTS INCOrganizationADP OF THE SNFsince 11/01/2023
NOLAND PHARMACY LLCOrganizationADP OF THE SNFsince 07/01/2023
WARREN AVERETT LLCOrganizationADP OF THE SNFsince 06/01/2022

CMS files one row per role, so the 43 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.3M
Net patient revenuemost recent cost report
+7.9%
Operating marginrevenue minus expenses
$447K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 5%Other / private 43%

This home reported $447K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$280per resident / day
operating cost
$8,497per month
≈ monthly operating cost
$304per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Alabama Medicaid page.

Typical monthly cost in Alabama
$8,334/mo
Nursing home (semi-private)
$8,787/mo
Nursing home (private)
$4,425/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 015369. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2021-05-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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