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Pine Haven Rehabilitation And Wellness Center

4525 St Stephens Road, Eight Mile, AL 36613 · For profit - Individual · 172 certified beds · (251) 452-0996 Medicare & Medicaid certified

Call the home — (251) 452-0996 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 3 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4230 St Stephens Rd · (251) 456-8888 · Call to confirm hours
Pharmacy
4544 Saint Stephens Rd · (251) 330-1631 · Call to confirm hours
Grocery
4731 St Stephens Rd · (251) 456-2402 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
429 S Shelton Beach Rd · (251) 219-6446

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 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 increased5.7%12.0%15.4%better
Long-stay residents who lose too much weight4.9%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.1%1.0%0.9%better
Long-stay residents with a urinary tract infection0.7%2.4%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star 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 injury2.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened4.0%12.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.0%24.5%18.9%better
Long-stay residents given the seasonal flu vaccine86.7%94.8%95.3%typical
Long-stay residents with pressure ulcers5.1%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control7.6%12.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table42.6%21.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine32.7%80.3%79.4%worse
Short-stay residents rehospitalized after admission18.3%24.8%22.6%better
Short-stay residents with an outpatient ER visit9.6%11.3%12.0%better
Long-stay hospitalizations per 1,000 resident days2.671.961.67worse
Long-stay outpatient ER visits per 1,000 resident days1.561.701.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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.

54.9% 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 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.9%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
27.8%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 27.8% 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 36 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 0.46 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF54.9%CMS range 41.4–72.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.2–16.310.7%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 discharge27.8%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 discharge30.6%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 discharge19.4%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 identified48.0%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.0%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 worsened4.0%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 hospitalization8.2%CMS range 4.4–17.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 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

0.44
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.44
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.40
RN hoursweekends
45.7%
Total nursing turnover
21.4%
RN turnover

How full it usually is: this home is certified for 172 beds and averages 146.1 residents a day — about 85% occupied, or roughly 26 beds typically open. It usually has some room. 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 is below 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 3.07 hrs/resident/day on weekends vs 3.81 on weekdays — 19% thinner on weekends. RN hours go from 0.45 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

9
deficiencies at the latest standard inspection (2022-10-19)
7
at the previous standard inspection (2021-06-08)

Deficiencies are more than at the previous inspection — worsening. 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 3 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.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2024-05-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    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 review, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative file, the facility failed to protect residents from abuse. On 02/08/2023 Resident Identifier (RI) #5's was verbally abused by RI #6. On 02/09/2023 RI #3 was physically abused by RI #2. On 05/21/2024 RI #8 and RI #9 were each verbally abused by the other. The facility further failed to substantiate the occurrences as abuse. These deficient practices affected RI #'s 3, 5, 8 and 9, four of 14 sampled residents. This deficiency was cited as a result of the investigation of complaint/report numbers AL00043323, AL00043305 and AL00047916. Findings include: Review of a facility policy titled ABUSE PREVENTION with a history date of 07/2018, revealed the following: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: . other residents .…

    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 · E2022-10-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and a copy of the facility's RESIDENT BILL OF RIGHTS, the facility failed to ensure 26 of 89 residents' rooms were found in a homelike condition. This affected 26 of 89 rooms observed during the survey. Findings Include: A review of the RESIDENT BILL OF RIGHTS with a most recent review date of 11/17, revealed, Each resident has a right to a dignified existence, . and in an environment that promotes maintenance or enhancement of (his or her) quality of life, . A. Facility residents have the right to: . 33. A safe clean, comfortable home like environment. On 10/11/2022 04:33 PM during the initial tour, the following observations were made by the surveyor: 10/11/2022 04:57 PM Area Locator (AL) 21 patchy touched up paint, 10/11/2022 04:58 PM AL 22 wall paint was scraped, 10/11/2022 05:02 PM AL 23 wall by beds were patched and painted different color, 10/11/2022 05:25 PM AL 26 wall paint was scraped, 10/11/2022 05:27 PM AL 25 walls behind bed patched up paint behind door beds, 10/11/2022 05:30 PM AL 24 walls by bed were patched up paint with different…

    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 · D2022-10-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 an observation, interviews and review of facility policies titled, . SMALL VOLUME NEBULIZER THERAPY and . SELF ADMINISTRATION PROTOCOL ., the facility failed to ensure the licensed nurse remained with (Resident Identifier) RI #55, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #55 received a nebulizer treatment on 10/11/2022. This deficient practice affected RI #55; one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: Review of facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: .RESPONSIBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 10. Assist/instruct resident to close lips around the mouthpiece. 11. Instruct to inhale deeply and hold for several seconds before exhaling. 12. Encourage and instruct resident to cough at completion of treatment. A second policy titled, . SELF ADMINISTRATION PROTOCOL . with a revision date of 8/16,…

    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 before2022-10-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS with a revision date of 11/17, the facility failed to provide evidence Resident Identifier (RI) #110's physician and sponsor were notified when RI #110 had ant bites to his/her left arm, left lower abdomen, and under his/her neck. This deficient practice affected RI #110, one of one resident sampled for notification. Findings Include: Facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, documented: . POLICY: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, . PROCEDURE: . d. Any accident or incident . The Incident Log documented RI #110 on 10/10/2022 at 7:00 AM . Incident type: Insect Bite . Raised Red Area . Resident room . In-house treatment . On 10/10/2022, RI #110's Resident Incident Report documented: . staff was providing care and noted several ants on the pillow where the resident'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-19 · 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 an interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) 55's Minimum Quarterly Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/22 was accurately coded to reflect RI #55 was receiving oxygen. This deficient practice affected RI #55, one of three sampled resident's whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: Section O: Special Treatments, Procedures, and Programs Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. O0100: Special Treatments, Procedures, and Programs Facilities may code treatments, programs and procedures that the resident…

    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 · D2022-10-19 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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, review of Resident Identifier (RI) #98's medical record including the PASRR (Pre-admission Screening and Resident Review) Screening & Results, and documents provided by the facility (the Regulatory Requirements) used as their guidance for the pre-admission screening process, the facility failed to ensure a valid Level 1 PASRR was completed for RI# 98. This affected RI #98, one of five residents whose Pre-admission Screening and Resident Reviews were reviewed for completion. Findings Include: A facility document dated October 15, 2022, documented: (Name of Facility) does not have a Policy or Procedure regarding PASRR however we follow the federal guidelines. A review of RI #98's . PASRR Level 1 Screening & Results for Mental Illness . Intellectual Disability . Related Condition . with a screening date of 5/20/21, revealed, . MAY REQUIRE A LEVEL II . For compliance with Federal and State PASRR regulations, Admitting NFs (Nursing Facilities) must: Report this admission to the OBRA…

    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 · D2022-10-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure a care plan was developed/implemented for the following residents: 1) Resident Identifier (RI) #71's newly identified Pressure Ulcer, 2) RI #81's diabetes and insulin use, and 3) RI #55's use of oxygen. These deficient practices affected RI #'s 71, 81, and 55, three of thirty-one residents whose care plans were reviewed. Findings Include: The facility's COMPREHENSIVE PERSON CENTERED CARE PLANS policy dated 3/18, revealed the following: POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . PROCEDURE: . 5. For each problem, need, or strength a resident-centered goal is developed. 1) RI #71 was admitted to the facility on [DATE] with diagnoses including Repeated Falls and Adult Failure to Thrive. The Weekly Skin…

    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 · D2022-10-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to review and revise the care plan for Resident Identifier (RI) #14 regarding a hand splint that was not in use during the survey. This affected RI #14, one of 31 residents whose care plans were reviewed. Findings Include: Review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, with a last review date of 3/18, revealed, . POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan or Baseline Care Plan will be updated . RI #14 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Parkinson's Disease and Persistent Vegetative State. The Quarterly MDS (Minimum Data Set Assessment) dated 10/02/2022 revealed, .…

    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 · D2022-10-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 the facility's policy titled, . SMALL VOLUME NEBULIZER THERAPY, the facility failed to ensure Resident Identifier (RI) #55's nebulizer mask was stored in a covering on three of three days of the survey. This deficient practice affected one of one resident sampled for nebulizer administration. Findings Include: Review of the facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: . RESPONSBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 15. Store in a labeled plastic bag. RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. RI #55's Physician Orders for October 2022 revealed RI #55 had orders for . BUDESONIDE 0.25MG (Milligrams)/2ML (Milliliters) SUSP (Suspension) ONE (1) AMPULE PER NEBULIZER TWICE DAILY . FORMOTEROL 20 MCG (Micrograms)/2 ML NEB (Nebulizer) TWICE DAILY DX (diagnosis): SOB…

    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 · D2022-10-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 reviews, a review of [NAME] and [NAME], Fundamentals of Nursing, NINTH EDITION, and the Facility's form titled, Medication Administration-General Guidelines, the facility failed to provide evidence the licensed nurse was consistently documenting on the resident's eMAR (electronic Medication Administration Record) the administration of the resident's insulin. This affected RI #81, one of three residents sampled for Medication Administration. Findings Include: A review of [NAME] and [NAME]'s Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: . Chapter 26 Documentation and Informatics . Informatics and Information Management in Health Care . A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry. Review of facility's form titled, Medication Administration-General Guidelines dated 1/15, documented, POLICY: Medications are administered as prescribed, in accordance with good nursing principles and…

    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 15 citations
  • Potential for harm · F2021-06-08 · tag F0761 — failed to label and store drugs safely — widespread
    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 observations, interviews, and review of the facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS, the facility failed to ensure expired mediation and medical supplies were discarded after the expiration date. This deficient practice was observed in four of four medication storage areas in the facility. Findings include: The facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS dated January 2015, documented POLICY: Time frames for expiration of medications / solutions are to be followed per manufacturer's recommendation . RESPONSIBILITY All Licensed Nursing Personnel . PROCEDURE: 1. Medications will be discarded by the product expiration date OR the date on which the suggested length of time after opening the product has passed, whichever occurs first . On 6/7/2021 at 11:23 AM, an observation of the A-wing medication storage area was conducted with Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN). Banophen, an antihistamine used to treat pain and itching, had an expiration date of September 2020 and Geri Tussin, cough medicine, had 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 · F2021-06-08 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview, the facility failed to have an effective pest control program so that flying insects were not observed in the kitchen. This deficient practice had the potential to affect all residents who received food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) completed by Employee Identifier (EI) #3, the Director of Nursing and dated 6/7/2021 indicated the facility had a total of 126 residents; 12 of which received nutrition by way of a tube feeding. Findings include: During a tour of the kitchen on 6/6/2021 at 9:47 AM, with EI #9, the Certified Dietary Manager (CDM), there were a small number of flying insets observed near the back door. During the lunch tray line observation on 6/7/2021 at 11:15 AM, multiple flying insects were observed in the kitchen area. The insects landed on cups, food, and pieces of cake on the residents' food trays. Two dietary staff members were observed fanning their hands to prevent flies from landing on the food. A staff member who observed the insects replaced the cake. Two of the dietary…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-08 · 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 interview, review of Resident Identifier (RI) #45's medical record and the facility's policy titled MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure RI #45's Quarterly MDS dated [DATE] indicated the resident was receiving hospice services. This deficient practice affected RI #45; one of 41 sampled residents. Findings include: The facility's policy titled MDS ASSESSMENT dated November 2017, documented POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care is a means by which the facility can track changes in a resident's status . PROCEDURE: . 2. Non-Medicare Covered Residents Upon admission, discharge, quarterly and annual reviews, an MDS assessment will be completed as per Federal/State requirements . RI #45 was admitted to the facility on [DATE]. According to the RI #45's June 2021…

    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 · D2021-06-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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, review of Resident Identifier (RI) #75's medical record and the facility's policy titled FINGERNAILS/TOENAILS CARE, the facility failed to provide nail care to RI #75, a resident assessed as requiring extensive assistance with personal hygiene and bathing, to ensure the resident's fingernails were cleaned. This deficient practice affected RI #75; one of one resident reviewed for Activities of Daily Living. Findings include: The facility's policy titled FINGERNAILS/TOENAILS CARE dated October 2009, documented POLICY: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. RESPONSIBILITY: Nursing Assistant of Licensed Nurse Key Procedural Points: 1. Nails can be partially cleaned during bath care. 2. Nursing Assistants do not trim the nails of diabetic residents. 3. Nail care includes daily cleaning and regular trimming . RI #75 was admitted to the facility on [DATE]. RI #75's Quarterly Minimum Data Set with an assessment reference…

    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 · D2021-06-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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, and review of Resident Identifier (RI) #70's medical record, the facility failed to consistently provide wound care to RI #70's non-pressure chronic left foot ulcer as ordered by the physician. This deficient practice affected RI #70; one of three sampled residents reviewed for non-pressure related wounds. Findings include: RI #70 was admitted to the facility on [DATE] with a medical history to include diagnoses of: Non-pressure chronic ulcer of the left foot and Type II Diabetes Mellitus with foot ulcer. RI #70's admission Minimum Data Set with an assessment reference date of 4/7/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status of 15. RI #70 was assessed as having a diabetic foot ulcer during this assessment period. According to a review of RI #70's medical record, on 5/10/2021, the resident was transferred and admitted to a local hospital. RI #70 returned to North Mobile Nursing and Rehabilitation Center on 5/14/2021 with 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-08 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 interview and review of Resident Identifier (RI) #60's medical record, the facility failed to adequately monitor the effects of thyroid medication for RI #60 when they failed to ensure physician ordered laboratory tests were done. This deficient practice affected RI #60; one of five sampled residents reviewed for unnecessary medications. Findings include: RI #60 was readmitted to the facility on [DATE] with a medical history to include a diagnosis of Hypothyroidism. According to RI #60's medical record, on 12/17/2019 the resident was ordered to have a TSH (Thyroid-Stimulating Hormone) IN 6 WEEKS AND EVERY 3 MONTHS DX (diagnosis): HYPOTHYROIDISM According to RI #60's medical record, on 12/18/2019 the resident was ordered LEVOTHYROXINE (a medication used to treat Hypothyroidism) 88 MCG (microgram) TABLET ONE (1) TABLET BY MOUTH 30 MINS (minutes) BEFORE BREAKFAST DX: LOW THYROID LEVELS to begin on 1/22/2020. A review of RI #60's medical record revealed on 5/11/2021, a TSH laboratory test was done, which…

    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 · D2021-06-08 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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 interview, review of Resident Identifier (RI) #60's medical record and the facility's policy titled LABORATORY TESTS, the facility failed to promptly notify the physician of RI #60's abnormal laboratory test result. This deficient practice affected RI #60; one of 41 sampled residents. Findings include: The facility's policy titled LABORATORY TESTS dated November 2017, documented POLICY: . Lab tests are completed as ordered by the physician or physician extended (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) . RESPONSIBILITY: All Licensed Nursing Personnel monitored by Director of Nursing or Designee . PROCEDURE: 1. Licensed Nurse, or designee, shall obtain the labs ordered by the physician or physician extender . 9. The physician or physician extender will be promptly notified of abnormal results according to facility policy. 10. The Licensed Nurse, or designee, will review all labs scheduled routinely to ensure all scheduled labs have been drawn and results have been received .…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-04-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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, medical record reviews and the facility's policy titled, A.M CARE, the facility failed to ensure Resident Identifier (RI) #11's, RI #111's and RI #117's call bell was within reach. This affected three of thirty two residents sampled residents. Findings include: The facility's policy titled, A.M. CARE, dated October 2009, documented POLICY: . RESPONSIBILITY: All . PROCEDURE: .11. Place call light within easy reach. 1) RI #111 was admitted to the facility on [DATE]. On 4/9/2919 at 8:23 AM, 4/9/2019 at 10:03 AM, 4/9/2019 at 2:27 PM and 4/11/2019 at 10:24 AM, RI #111's call light was observed behind the bed on the floor; not within the resident's reach. On 4/11/19 at 10:42 AM, Employee Identifier (EI) #17, a Licensed Practical Nurse, (LPN) entered RI #111's room. RI #111 asked EI #17 where the call light was and EI #17 pulled it from behind the bedside table and placed it on RI #111's bed. EI #17 was asked where the call light was and she said behind the bed. When asked where it…

    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 before2019-04-11 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 review of facility policies titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS and GLUCOSE MONITORING VIA (by way of) GLUCOMETER, the facility failed to notify Resident Identifier (RI) #216's physician when the resident's blood sugar (BS) was greater than 400mg/dl (milligrams per deciliter) on 1/2/2019. This deficient practice affected RI #216, one of four residents sampled for notification. Findings include: The facility's policy titled, GLUCOSE MONITORING VIA GLUCOMETER dated August 2014, revealed the following: . RESPONSIBILITY: Licensed Nurses PROCEDURE: . 3. Notify the physician of abnormal results, per MD (Medical Doctor) order . 4. The Nurse will document notification of the MD in the Interdisciplinary Progress Notes and indicate any new order . The facility's policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS dated November 2017, revealed the following: . RESPONSIBILITY: All Licensed Nursing Personnel. PROCEDURE: 1. Guideline for notification of…

    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 · D2019-04-11 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 interview, review of Resident Identifier (RI) #149's medical record and the facility's policy's titled DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY, the facility failed to ensure RI #149's discharge notice dated 2/11/2019 included the name, address (mail and email) and telephone number of the entity to which the resident and/or the resident's representative can appeal the resident's discharge, which is the Alabama Medicaid Agency and the name address (mail and email) and telephone number of the Office of the State Long-Term Care Ombudsman. This deficient practice affected RI #149, one of five sampled residents reviewed for discharge. Findings include: The facility's policy titled, DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY dated July 2018, documented POLICY: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not . RESPONSIBILITY: All staff, monitored by the Director of Nursing and Executive Director.…

    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 · D2019-04-11 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 interview, review of Resident Identifier (RI) #163 and RI #567's medical record, the facility failed to provide written notice of the bed hold policy when RI #163 and RI #567 were transferred to a local hospital. This deficient practice affected RI #163, one of six residents reviewed for hospitalization and RI #567, one of five residents reviewed for discharge. Findings include: 1) RI #567 was admitted to the facility on [DATE]. According to RI #567's FACESHEET, the resident was transferred/discharged to a local hospital on 1/11/2019. In an interview on 4/11/2019 at 12:39 PM, Employee Identifier (EI) #1, the Administrator confirmed the facility did not issue RI #567 and/or the resident's representative written notice of the facility's bed-hold policy. 2) RI #163 was admitted to the facility on [DATE]. According to RI #163's FACESHEET, the resident was transferred to a local hospital on 3/15/2019. In an interview on 4/11/2019 at 5:02 PM, EI #1, the Administrator stated the facility had only discussed bed…

    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 · D2019-04-11 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure a significant change assessment was completed for Resident Identifier (RI) #137. This affected RI #137, one of thirty-two sampled residents. Findings include: A review of the facility policy titled, MDS ASSESSMENT, updated 11/17, revealed, POLICY: . PROCEDURE: . 6. The Interdisciplinary Team as designated will complete specified portions of the MDS . The RN (Registered Nurse) designated by the facility will assure that all disciplines have completed their portion of the MDS. RI #137 was re-admitted to the facility on [DATE], with diagnoses to include Heart Failure, Chronic Atrial Fibrillation, and Dementia. RI #137's Significant Change MDS with an assessment reference date of 2/20/2019, revealed the assessment tool had been opened and initiated but incomplete. On 4/11/2019 at 5:06 PM, an interview was conducted with Employee Identifier (EI) #12, the Licensed Practical Nurse…

    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 · D2019-04-11 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure a Quarterly MDS assessment was completed timely for Resident Identifiers (RI) #121 and RI #165. This affected two of thirty two residents whose MDS assessments were reviewed for timely completion. Findings Include: The facility's policy titled, MDS ASSESSMENT dated November 2017, revealed, POLICY: . PROCEDURE: . 6. The Interdisciplinary Team as designated will complete specified portions of the MDS . The RN (Registered Nurse) designated by the facility will assure that all disciplines have completed their portion of the MDS. RI #121 was admitted to the facility on [DATE], with a diagnosis of Unspecified Cerebrovascular Disease. A review of RI #121's Quarterly MDS, on 4/11/2019 at 1:10 PM, revealed RI #121 had an open, incomplete MDS assessment dated [DATE]. RI #165 was admitted to the facility on [DATE], with a diagnosis of Encephalopathy. A review of RI #165's Quarterly MDS,…

    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 · D2019-04-11 · 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, record review, interviews, and a facility policy titled,DRESSING CHANGE, the facility failed to ensure a licensed staff member removed gloves or performed hand hygiene after removing a soiled dressing and before cleaning a wound during the wound care of Resident Identifier (RI) #154. This affected RI #154, one of one resident observed for wound care. Findings include: The facility's policy titled,DRESSING CHANGE, with a review date of October 2009, documented POLICY: A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment.PROCEDURE: . 13. Remove the dressing. 14. Assess the dressing for the amount, color, consistency and odor of drainage and discard in waste bag. 15. Remove exam gloves and discard in waste in waste bag .17. Apply gloves. 18. Cleanse wound . RI #154 was admitted to the facility on [DATE] with diagnoses to include Pressure Ulcer of Right Heel, Unspecified Stage and Pressure Ulcer of Left Hip, Unspecified…

    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 · D2019-04-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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, record review, and interview, the facility failed to ensure there was medical justification for the use an urinary catheter for Resident Identifier (RI) #163. This deficient practice affected RI #163, one of one resident observed with a urinary catheter. Findings include: RI #163 was readmitted to the facility on [DATE], with a diagnosis of Acute Respiratory Distress. On 4/10/2019 at 4:28 PM, RI #163 was observed with a urinary catheter. The catheter was in a privacy bag, located on the right side of the resident's bed. A review of RI #163's medical record did not reveal a diagnosis or physician's order for the use of the urinary catheter. In an interview on 4/11/2019 at 4:12 PM, Employee Identifier (EI) #2, the Director of Nursing (DON), acknowledged RI #163 had a catheter. EI #2 was asked, did RI #163 have an order or diagnosis for the use of the urinary catheter prior to 4/10/2019. EI #2 replied, the resident came from the hospital on 3/25/2019 with the catheter but there was no an order…

    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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
ALABAMA SEVEN SNF OPCO HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2025
GEFEN AL SEVEN OPCO HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 11/01/2025
GEFEN NG TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF24%since 11/01/2025
CCG ALABAMA OPCO HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2025
DOROS GENERATION TRUST U/A/D 1/3/12OrganizationINDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNFsince 11/01/2025
GPN FAMILY TRUST U/A/D 4/28/08OrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2025
USHCG AL SEVEN OPERATIONS HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2025
YEHUDA HERZ 2025 NG FAMILY TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNFsince 11/01/2025
YH AL 7 OPERATIONS HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2025
APFEL, STEPHENIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
HERZ, YEHUDAIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
KAPLAN, MORDECHAIIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2025
ROSENBLUM, YITZCHAKIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2025
SHIBE, BENIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2025
CCG ALABAMA CONSULTING HOLDINGS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2025
US HEALTHCARE CONSULTING HOLDINGS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/14/2026
CARLETON, ALTHIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
DIXON, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
HAYES, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/09/2026
PLASKI, TINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
SKELTON, FREDERICKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2025
MALTA ALABAMA PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 11/01/2025
NORTH MOBILE SNF PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 02/09/2026

CMS files one row per role, so the 38 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

$15.3M
Net patient revenuemost recent cost report
+10.0%
Operating marginrevenue minus expenses
$1.4M
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 5%Other / private 7%

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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

$257per resident / day
operating cost
$7,826per month
≈ monthly operating cost
$286per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). 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 015183. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-10-19, 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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