Magnolia Ridge

Location & what’s nearby

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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

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.

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.

56.6% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 19.2% 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 26 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% 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.

Staffing

How full it usually is: this home is certified for 148 beds and averages 54.1 residents a day — about 37% occupied, or roughly 94 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 4.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.80 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 3.61 hrs/resident/day on weekends vs 4.85 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.84 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

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.

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.

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.

43 citations, most serious first. The 29 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · L2025-06-05 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record review, and the Administrator's and Director of Nursing's Job Description the administration failed to provide oversight and guidance to the facility's staff to ensure policies and procedures were developed and implemented to ensure: staff knew what behaviors and abuse should be reported and communicated; residents with Mental Illness were determined to be appropriate for the facility and received the appropriate treatment and medications as ordered; staff communicated resident's needs pre-admission to ensure medications were administered as expected following a transition of care from hospital to the facility; and management staff identified medications that had not been administered. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 05/13/2025 at 3:30 PM the Administrator (ADM) and Director of Nursing (DON) were provided a copy of the IJ…

  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 plan of correction
• Immediate jeopardy · L2025-06-05 · tag F0837 — widespread
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, record reviews, and the job description for Center Sr. Executive Director the Governing Body failed to provide oversight to ensure residents were free from abuse, neglect, and significant medications errors. Further the Governing Body failed to ensure the facility staff responsible for administering medications and parenteral fluids via PICC were trained on the standards of practice. The Governing Body further failed to ensure facility staff were trained on proper resident care for residents with a PICC. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.70 Administration. On 05/28/2025 at 9:37 PM, the interim Administrator (ADM), the interim Director of Nursing (DON), and the Market Clinical Advisor were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Administration and at F837-Governing Body.The IJ began 05/02/2025…

  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 plan of correction
• Immediate jeopardy · L2025-06-05 · tag F0841 — widespread
  Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
  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, and review of a facility policy titled, Genesis Physician Services, the facility's Medical Director (MD) failed to ensure the appropriateness and quality of Resident Identifier (RI) #9's medical care. On 04/07/2025 a change of condition was noted in RI #9's medical record related to bleeding from a surgical incision. The CRNP (Certified Registered Nurse Practitioner) was notified, and orders were obtained to hold RI #9's Apixaban (Eliquis) 5 milligrams (mgs), ordered twice daily, for three days. RI #9's Eliquis was held on 04/07/2025 at 8 PM until 04/10/2025 at 8PM.On 04/09/2025 the MD (Medical Director) made an acute care visit for RI #9. The MD's note indicated that he was not aware of ongoing concerns regarding bleeding from RI #9's surgical incision and RI #9's current lab results. The lab results documented on the MD's note dated 04/09/2025 were not the most current results. The MD reported RI #9's Eliquis should have continued to be held, but he expected the…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-05 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 reviews the facility failed to ensure Resident Identifier (RI) #119, RI #76, and RI #9 were free of a significant medication errors. Specifically, the facility failed to ensure: 1) RI #119's monthly paliperidone (Invega) injection was administered on 01/24/2025 and 02/24/2025. RI #119 had a history of cursing and yelling in the facility and on 03/18/2025 RI #119 threatened to kill people in the facility. RI #119 was sent to the hospital for evaluation. On 04/01/2025 RI #119 hit RI #53 in the face twice with a closed fist. 2) Further the facility failed to ensure RI #76's morning medications including Imdur (Isosorbide Dinitrate), Lacosamide, Keppra, Amlodipine, and Losartan were administered on 05/06/2025 when RI #76 requested that Licensed Practice Nurse (LPN) #42 administer the medications after he/she ate breakfast. The LPN did not administer the medications. On 05/07/2025 RI #76's blood pressure was 200/97. It was determined the facility's noncompliance with one or more…

  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
• Immediate jeopardy · Jcited before2025-06-05 · 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 a facility policy titled, Change in Condition: Notification of, the facility failed to ensure the physician was when a significant change was identified on 04/07/2025 when Resident Identifier (RI) #9 was noted to have continued bleeding from a surgical incision ten days after being admitted and 13 days after the surgical procedure. The facility further failed to ensure the physician was notified on 04/09/2025 Resident Identifier (RI) #9's hemoglobin was 7.7 g/dL (grams per deciliter). On 04/07/2025 a change of condition was noted in RI #9's medical record related to bleeding from his/her surgical incision. The Certified Registered Nurse Practitioner (CRNP) was notified, and orders were obtained to hold RI #9's Eliquis for three days and obtain Complete Blood Count (CBC) on 04/08/2025. RI #9's Abixipan (Eliquis) was held on 04/07/2025 at 8 PM until 04/10/2025 at 8 PM. On 04/09/2025 at 10:41 AM the lab reported hemoglobin of 7.7 g/dL (low at 12, critical at 6.5).…

  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
• Immediate jeopardy · Jcited before2025-06-05 · 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 reviews, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRI) received by the State Agency, and review of the facility investigative file, the facility failed to ensure residents were free from abuse perpetrated by other residents and failed to ensure Resident Identifier (RI) #9 was free from neglect.Specifically the facility failed to ensure:1) Resident Identifier (RI) #53 was free from verbal and physical abuse perpetrated by RI #119 on 04/01/2025 when RI #119 hit RI #53 in the face twice with a closed fist, as witnessed by several staff members. RI #53 had a red mark on his/her face. Staff said, someone hit in that manner would feel hurt and confused.During the investigation, it was revealed that RI #119 was admitted to the facility with diagnoses to include Schizoaffective Disorder. The facility failed to ensure the required Preadmission Screening and Resident Review (PASRR) screening process was completed for RI #119 prior to…

  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 plan of correction
• Immediate jeopardy · Jcited before2025-06-05 · 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, resident record reviews, review of a facility policy titled, Abuse Prohibition, review of Facility Reported Incidents (FRI) received by the State Agency (SA) and review of the facility investigative file, the facility failed to ensure nurses and staff reported verbal abuse to the abuse coordinator and the SA and took actions to prevent escalating resident on resident abuse in the facility.During the investigation of the FRI alleging physical abuse occurred on 04/01/2025 when Resident Identifier (RI) #119 hit RI #53 in the face, staff told surveyors they did not always document or report RI #119's behavior of yelling and cursing, which was a daily behavior since admission on [DATE], even when it was directed at other residents.Because RI #119's verbally abusive behaviors continued, and escalated, on 03/18/2025 RI #119 threatened to kill people in the facility. The incident was not identified as potential abuse, was not reported as an allegation of abuse, and was not investigated in a manner…

  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 plan of correction
• Immediate jeopardy · J2025-06-05 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 Prohibition, during and after the facility investigation, the facility failed to ensure thorough investigations were conducted and appropriate corrective actions were taken or interventions were developed to ensure residents in the facility were protected from residents with unmanaged, escalating abusive behaviors and to prevent further abuse.Resident Identifier (RI) #119 had verbally abusive behaviors which escalated on 03/18/2025 when RI #119 threatened to kill people in the facility. The incident was not identified as potential abuse, was not reported as an allegation of abuse, and was not investigated in a manner to prevent further abuse. On 04/01/2025 RI #119 hit RI #53 in the face twice with a closed fist. The facility investigation was not thorough and effective corrective actions were not developed to ensure the protection and prevention of abuse of residents. RI #119 continued to have access to RI #53 during the survey…

  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 plan of correction
• Immediate jeopardy · Jcited before2025-06-05 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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, and review of a facility policy titled Pre-admission Screening for Mental Disorder and or Intellectual Disability Patients, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) screening process was completed for Resident Identifier (RI) #119 for a Level I or Level II determination to be made about the level of services RI #119 required for Mental Disorder or Mental Illness (MI) before admission to the facility. RI #19 was admitted to the facility on [DATE] and had a diagnosis of Schizoaffective Disorder which is a Mental Illness.On 03/18/2025 RI #119 threatened to kill people in the facility. On 04/01/2025 RI #119 hit another resident, RI #53, in the face twice with a fist. A Level I determination was not made for RI #119 until 05/08/2025 during the survey.It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to…

  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
• Immediate jeopardy · Jcited before2025-06-05 · 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 interviews, resident record review, and review of a facility policy titled, Medication Administration General Guidelines, and review of ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE the facility failed to ensure licensed staff implemented physician orders and followed standards of practice when they documented administration of Resident Identifier (RI) #9's intravenous (IV) medications. Specifically, on 05/14/2025 the facility submitted a plan to remove the immediacy of jeopardy that included . On 5/14/25, the DON [Director of Nursing (Former DON #2)] and/or designee reviewed Medication Administration Records for the last 60 days and no additional concerns were identified. Upon review of documentation in RI #9's medical record it was identified that of the 42 times the facility's staff documented that Zosyn was administered to RI #9, five doses were documented as administered days later on 05/14/2025 by a Registered Nurse (RN) #25 who was not clocked in 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-06-05 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids 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 interviews, record review, and review of facility policies titled, Vascular Access Devises and Infusion Therapy Procedures- Maintaining Patency of Peripheral and Central Vascular Access Devices and Administration of IV Fluids and Medication - SETTING UP A PRIMARY INFUSION (HYDRATION OR MEDICATION, and the ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE the facility failed to ensure Resident Identifier (RI) #9's intravenous antibiotics (IV) were administered in accordance with professional standards of practice. 1) The facility failed to ensure a process was implemented to ensure RI #9's IV antibiotics were ordered and administered upon RI #9's re-admission on [DATE]. Seven doses of Piperacillin-Tazobactam (Zosyn) were not administered on 05/03/2025, 05/04/2025, and 05/05/2025. Two doses of Daptomycin were not administered on 05/03/2025 and 05/04/2025. 2) The facility further failed to ensure facility staff followed their policy for administering and documenting…

  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
• Immediate jeopardy · J2025-06-05 · tag F0725 — failed to have enough nursing staff — isolated
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, the facility failed to ensure a Registered Nurse (RN) was consistently scheduled to administer Resident Identifier (RI) #9's 12:00 AM dose of intravenous (IV) antibiotic, Piperacillin-Tazobactam (Zosyn). Six doses of RI #9's Zosyn scheduled to be administered at 12: AM were either not documented as administered or documented days later by RN #25 who was not clocked in at the time the documented doses were scheduled. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.35 Nursing Services at F725- Sufficient Nursing Staff. On 05/28/2025 at 9:37 PM, the interim Administrator, the interim DON, and the Market Clinical Advisor were provided a copy of the IJ template and notified of the finding of immediate jeopardy in the area of Nursing Services at F725- Sufficient Nursing Staff. The IJ began on 05/05/2025 and continued until 05/30/2025. 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-06-05 · 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 reviews, and review of a facility policy titled Behaviors: Management of Symptoms, the facility failed to ensure a behavior management process was implemented. Specifically, the facility failed to ensure staff understood what steps to take when resident behaviors were observed or reported, and staff took action to address behaviors and implement interventions and supervision instructions to protect residents in the facility from abuse and prevent escalation of RI #119's behaviors.RI #119 had a history of unmanaged behaviors in the facility including on 03/18/2025 when RI #119 threatened to kill people in the facility. RI #119 was evaluated at the hospital and returned to the facility on the same day without any new orders except a newly ordered medication. The facility failed to develop any plans for intervention or increased supervision of RI #119 to prevent RI #119 from having behaviors affecting others. RI #119's behaviors continued to escalate and on 04/01/2025 RI #119…

  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
• Immediate jeopardy · J2025-06-05 · 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 interviews, record review, and Review of Mosby's 2017 Nursing Drug Reference Book, the facility failed to ensure Resident Identifier (RI) 9's Apixaban (Eliquis) was not resumed on 04/10/2025 at 8:00 PM when RI #9 had an actively bleeding surgical incision and abnormal laboratory (lab) blood values. On 04/07/2025, a change of condition was noted in RI #9's medical record related to bleeding from a surgical incision. Certified Registered Nurse Practitioner (CRNP) #75 was notified, and orders were obtained to hold RI #9's Eliquis for three days. RI #9's Eliquis was held on 04/07/2025 at 8 PM until 04/10/2025 at 8 PM.On 04/09/2025 at 10:41 AM, the lab reported the Complete Blood Count (CBC) results that included hemoglobin of 7.7 g/dL (grams per deciliter), hematocrit of 25.9% (percent) and Red Blood Count (RBC) of 2.6 10 6/uL (microliters).On 04/09/2025 the Medical Director (MD) made an acute care visit for RI #9. The MD's note indicated that he was not aware of ongoing concerns regarding bleeding from RI…

  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
• Immediate jeopardy · J2025-06-05 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  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 a facility policy titled, Center Quality Assurance Performance Improvement (QAPI) Process, the facility's QAPI committee failed to identify that appropriate corrective actions had not been taken and no interventions were developed to ensure RI #53 was protected from RI #119 after RI #119 hit RI #53 in the face twice with a closed fist on 04/01/2025. RI #119 continued to have access to RI #53 until 05/08/2025 after a staff intervened to separate the residents when RI #119 was observed yelling, cussing, and behaving aggressively toward RI #53. RI #119 was placed on 1 to 1 supervision, resident RI #119 room assignment was changed to an alternate unit and room on the [NAME] Wing. It was determined the facility's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.75 Quality Assurance and Performance…

  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 plan of correction
• Immediate jeopardy · Jcited before2025-03-19 · 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 reviews, review of a facility policy titled Abuse Prohibition, 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, mental, and verbal abuse perpetrated by staff and residents. On 07/25/2023 around 9:15 AM Resident Identifier (RI) #60 was mentally abused by Certified Nursing Assistant (CNA) #41 and RI #287 was physically abused by RI #60 while outside at the smoking area with other residents and staff present to witness the abuse. RI #60, a resident with a history of behaviors toward staff, called CNA #41 names and CNA #41 responded by throwing a metal ashtray weighing over one pound at RI #60. The ashtray thrown by CNA #41 missed RI #60 and hit the wall behind the resident. RI #60 threw the ashtray back at CNA #41. The ashtray struck RI #287 in the head and cause injury. Staff summoned assistance and reported RI #60 hit RI #287…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-03-19 · 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, resident record reviews, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to ensure allegations of abuse were reported immediately by staff to a supervisor or the Administrator so action could be taken to investigate abuse and protect residents. Specifically, on 07/25/2023, a Certified Nursing Assistant (CNA) #39 failed to immediately report that she witnessed CNA #41 throw a metal ashtray weighing over one pound at RI #60. Further, CNA #40 failed to report the allegation of abuse immediately on 07/25/2023 around 10:00 PM when CNA #41 made a telephone call to tell CNA #40 she had thrown an ashtray at RI #60. CNA #40 failed to report what CNA #41 told her until the next day on 07/26/2023. Because CNA #39 failed to report abuse immediately, CNA #41 remained in the facility and continued working until almost 3:00 PM when her shift ended 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2025-03-19 · 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 interviews, medical record review, and review of facility policies titled, OPS111 Elopement of Patient, and OPS100 Accidents/Incidents, facility failed to ensure Resident Identifier (RI) #48 was supervised in a manner that staff knew of his/her whereabouts and that he/she did not leave the facility without staff knowledge. The facility failed to have a system to ensure residents were unable to exit the facility without staff's knowledge and without supervision. The facility further failed to ensure the Physical Therapy Assistant (PTA) did not leave RI #48 in an unsafe area without taking measures to ensure the resident's safety when he observed RI #48 off the facility property on 02/01/2025. On 02/01/2025 around 8:40 AM, the PTA observed RI #48 in his/her wheelchair near the road, across the street from the facility. The PTA did not take immediate action, but instead parked his vehicle in the facility parking lot and entered the facility to report RI #48's whereabouts to nursing staff. 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-19 · 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, and review of a facility policy titled Behavioral Health Care Services, the facility failed to ensure staff utilized and implemented behavior management care plan approaches to manage Resident Identifier (RI) #60's verbal behaviors, outbursts, and cursing. Specifically, on 07/25/2023 RI #60 was outside in the smoking area with other residents (RI #287 and RI #488) and staff Certified Nursing Assistant (CNA #39 and CNA #41). RI #60 was cursing and calling staff names. CNA #41 failed to respond to RI #60 calmly and gently, and instead, CNA #41 picked up an ashtray and threw it at RI #60. The ashtray did not hit RI #60 but caused RI #60's behavior to escalate. RI #60 picked up the ashtray and threw it back at CNA #41. The ashtray did not hit the CNA, but the ashtray did hit another resident, RI #287 on the head and caused injury. It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious…

  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 · Past Non-Compliance
• Potential for harm · F2025-03-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, the facility's policies for Menus and Portion Control, the facility's Fall/Winter Menu for Week 3, and the Portion Control Chart posted in the facility's kitchen; the facility failed to ensure the correct food portions were served to residents for Mandarin Orange Sections at Supper on 03/02/2025 and for Puree [NAME] Stew without Corn, Puree Bread, Puree Tomato Soup, Mashed Potatoes, Tossed Salad, and Shredded Lettuce Salad served at Lunch on 03/04/2025. This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen. Findings include: The facility's policy for Menus, undated, included the following: . Policy Statement Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Procedures . 5. A Registered Dietitian/Nutritionist (RDN) . reviews and approves the menus. The RDN . will adjust the individual meal plan . as appropriate. 6. Menus will be served as written,…

  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 · Fcited before2025-03-19 · 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 observation, interview, the facility's policies for Food Storage: Cold Foods and Meal Distribution, the facility's Labeling and Dating Inservice, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent possible cross-contamination by allowing meat to thaw on a shelf 3.5 inches from the floor, incompletely covered meal plates to be delivered on an open cart to residents throughout the facility on 03/02/2025 for Supper, and a damaged Handwashing Sink with a draining issue and no cold water to be used by staff. The facility further failed to ensure Use By dates were used for sandwiches prepared for residents' snacks. This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen. Findings include: The facility's undated policy for Food Storage: Cold Foods, included the following: . Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 1. All food items will…

  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 · F2025-03-19 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure: 1.) the air filters for two of two Ice Machines were cleaned as recommended by the manufacturer; 2.) an in-use Handwashing Sink in the kitchen was repaired; 3.) a new fuse was obtained for the Dishwashing Machine; 4.) a Plate Lowerator (one of one), which would help keep food warm for the residents, was repaired. This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen. Findings Include: The U.S. FDA 2022 Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . During the initial kitchen tour on 03/02/2025 at 1:58 PM, the Dietary Manager (DM) said the dishwashing machine was normally a hot sanitizing rinse machine, but it had been temporarily converted to a chemical sanitizing machine. On 03/03/2025 at 11:21 AM, the Dietary Manager said the dishwashing machine's heated final rinse was not working because it needed 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-19 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 facility policies titled, Medication Administration Controlled Substances and Abuse Prohibition, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifiers (RI) #'s 15, 21, 40, 76, 79, 103, 108, and 113 were free from misappropriation of property when the resident's controlled substances were unable to be accounted for after Registered Nurse (RN) #33 removed the resident's controlled substances from the medication cart on 11/13/2024 on the 7 PM to 7 AM shift. This deficient practice affected RI #'s 15, 21, 40, 76, 79, 103, 108, and 113 eight of 11 residents reviewed for misappropriation of property, and affected two of two medications carts on the Rehab Hall. This deficiency was cited as a result of the investigation of a facility reported incident/complaint/report number AL00049756. Findings Include: The facility policy titled…

  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 · Ecited before2025-03-19 · 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 facility policies titled Medication Administration General Guidelines and Medication Administration Controlled Substances and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #'s 15, 21, 40, 76, 79, 103, 108 and 113 received their on the 7 PM to 7 AM shift on 11/13/2024 as ordered by the physician. This deficient practice affected eight of 11 residents residing on the Rehab unit reviewed for not receiving their medications as ordered by the physician. Findings Include: Cross-Reference F 602. Review of a facility policy titled, Medication Administration General Guidelines, dated 2007 and 01/2025, revealed the following: . GENERAL GUIDELINES . PROCEDURES . Medication Administration: 1. Medications are administered in accordance with written orders of the Prescriber . 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers…

  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 · Dcited before2025-03-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, and review of a facility policy titled, Change in Condition: Notification of, the facility failed to notify Resident Identifier (RI) #237's family/responsible party when RI #237's Ativan 1 mg (milligram) was decreased to 0.5 mg on 12/12/2024. This affected RI #237 one of one sampled resident reviewed for notification of change. This deficiency was cited as a result of the investigation of complaint/report number AL00042921. Finding Include: Review of a policy titled Change in Condition: Notification of, with an effective date of 11/28/2016, documented: . POLICY A Center must immediately inform the patient, . and notify, consistent with their authority, the patient's representative, where there is: . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment) . PURPOSE To provide appropriate and timely information about changes relevant to the…

  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 · D2025-03-19 · 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 interviews, observation, medical record review, and facility's policies titled, Safeguarding and Storage of Health Information Records and Medication Administration, the facility failed to ensure the Electronic Medication Administration Record (eMAR) screen was closed and did not reveal personal information concerning Resident Identifier (RI) #127. This was observed on 03/03/2025 during the evening medication pass and affected RI #127, one of 134 residents residing in the facility. Findings Include: A review of a facility policy titled, Safeguarding and Storage of Health Information Records, with a revision date of 05/01/2022 revealed the followings: . POLICY The Company will maintain reasonable administrative, technical, and physical safeguards to protect the privacy of protected health information (PHI) from use or disclosure that is in violation of federal and/or state regulations. PURPOSE To limit unauthorized access of protected health information (PHI) . 3.1. Do not leave health information…

  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 · D2025-03-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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, interview, and the facility's document titled, YOUR RIGHT . AS A NURSING HOME RESIDENT, the facility failed to maintain a safe, comfortable, and homelike environment as evidence by: 1) Exit door at end of 100 hall was scraped, dirty with an unknown black substance. The door was in view of residents on the hall. 2) Resident Identfier's (RI) #15, RI #92, and RI #340 bathrooms' ceiling tiles were missing. This deficient practice affected the residents on the 100 hall and RI #15, RI #92, and RI #340 bathrooms. This was cited as a result of the investigation of complaint/report number AL00042921. Findings Include: A review of a facility's document titled, YOUR RIGHT . AS A NURSING HOME RESIDENT, with no effective date revealed the following: . Federal law require us .to provide . a safe, clean, comfortable and homelike environment . On 03/02/2025 at 2:51 PM, RI #340's bathroom tiles were observed to be missing from the ceiling. On 03/02/2025 at 2:55 PM, the ceiling tiles in RI #92's bathroom were observed to be missing and the RI #92 stated the tiles had been…

  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 · D2025-03-19 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  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, a review of the facility's investigative file, and a review of a facility's policy titled, Grievance/Concern, the facility failed to ensure a Grievance/Concern filed on 05/15/2024 by Resident Identifier (RI) #117 and RI #117's Resident Representative (RR) was resolved when CNA #44 went back into RI #117's room to provide care on 05/31/2024 after being instructed not to enter RI #117's room. This deficient practice affected one of 29 sampled residents. Findings include: A review of the facility policy with a revised date of 07/19/2023 titled, Grievance/Concern documented: . POLICY . The patient/resident (hereinafter patient) has the right to voice grievances to the Center or other agency or entity that hears grievances . Such grievances include those with respect to care and treatment, which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. PURPOSE To assure prompt receipt…

  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 · D2025-03-19 · 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 observations, interviews, resident record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. 1.) Resident Identifier (RI) #69's quarterly Minimum Data Set assessment dated [DATE] was coded to reflected RI #69 was receiving tracheostomy care, invasive mechanical ventilator and non-invasive mechanical ventilator, when RI #69 was not receiving those special services. 2.) RI #60's annual MDS assessment dated [DATE] section A1500 was not coded accurately to reflect RI #60's Preadmission Screening and Resident Review (PASRR) Level II and Serious Mental Illness. These deficient practices had the potential to affect RI #69 and RI #60 two of 29 sampled residents whose MDS assessments were reviewed. Findings include: 1.) The A review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0…

  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

“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.

Fines & penalties

$392,125 in federal fines across 1 penalty.

• $392,125 — penalty dated 2025-03-19

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 GENESIS HEALTHCARE — 184 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 →

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

CMS files one row per role, so the 17 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

About 83% 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 $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 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

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