Magnolia Haven Health And Rehabilitation Center
603 Wright Street, Tuskegee, AL 36083 · For profit - Corporation · 111 certified beds · (334) 727-4960 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — 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 (1/5)
- about 21% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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
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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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 2 to 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.3% | 12.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.0% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 1.0% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.9% | 2.4% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 1.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.9% | 3.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.4% | 12.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.6% | 24.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 94.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.8% | 5.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 5.5% | 12.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.5% | 21.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 80.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.4% | 24.8% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.6% | 11.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.19 | 1.96 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.58 | 1.70 | 1.80 | better |
* 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.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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
How full it usually is: this home is certified for 111 beds and averages 85.4 residents a day — about 77% 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 2.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 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 2.36 hrs/resident/day on weekends vs 3.06 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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
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.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gdisputed · IDR2026-06-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 observation, record review, interviews, and a policy titled .Abuse, Neglect, and Exploitation the facility failed to ensure Resident Identifier (RI) # 90 was free from resident to resident physical abuse perpetrated by RI #57. The facility failed to implement timely and effective interventions to prevent resident to resident abuse on 04/15/2025 after RI #57 complained to staff about RI #90 entering his/her room without permission. On 04/16/2025, RI #57 pushed RI #90 from his/her room into the hallway, causing him/her to fall and sustain a laceration above the left eye and Contrast Tomography (CT) confirmed fractures of the left maxillary sinus wall and left orbital wall.This deficient practice affected RI #90, one of six sampled residents reviewed for abuse.This deficiency was cited as a result of the investigation of complaint/ report number #463612. Findings Include:Cross-Reference F740.On 04/16/2025 at 1:16 PM, the Alabama State Survey Agency received a Facility Reported Incident (FRI) 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.
- Potential for harm · F2026-06-30 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, the facility's policies for DIET MANUAL and MENUS, the facility's menus for Spring/Summer 2026, and the facility's posted SCOOP AND DIPPER SIZES; the facility failed to ensure a #10 dipper/scoop was used for Chopped Meat (Hamburger Steak) for Lunch on Tues. 6/23/2026, a #6 dipper/scoop was used for Puree Lasagna for Dinner on Tues. 6/23/2026, and a #10 dipper/scoop was used for Chopped Fried Chicken and a #10 dipper/scoop was used for Puree Chicken when serving Lunch on Wed. 6/24/2026. This affected residents receiving chopped meats, Mechanical Soft diets, and Puree diets; 36 of 84 residents receiving meals at the facility and had the potential to result in weight loss. The facility's policy for DIET MANUAL, revised 8/2017, included the following: . PROCEDURE: . 4. The diet manual is the reference for regular, texture-modified and therapeutic diet orders.5. The diet manual is used as the basis for the planned menu and menu modifications. The facility's policy for MENUS, revised 12/2023, included the following: . POLICY:Menus are planned to meet 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.
- Potential for harm · Fcited before2026-06-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interviews, a repair/service report, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to ensure food was frozen solid in the Reach-in Bread Freezer on 6/22/2026 and further failed to ensure the internal temperature did not reach 45 (degrees) Fahrenheit (F). This had the potential to affect 84 of 84 residents receiving meals from the facility's Food Service Department and possibly exposing them to food borne illness.The 2022 U.S. FDA Food Code included the following: . Temperature and time Control3-501.11 Frozen Food.Stored frozen FOODS shall be maintained frozen.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5 C (41 F) or less. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines3-501.16 Time/Temperature Control for Safety Food [TCS], Hot and Cold Holding.Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone 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.
- Potential for harm · F2026-06-30 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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, the Resident Council, and the facility's policy for FOOD FROM OUTSIDE SOURCES, the facility failed to ensure there was a refrigerated area for storage of food brought in to the residents by family and friends. Eleven of eleven residents attending Resident Council on 6/24/2026 affirmed they wanted refrigeration space to be able to store personal food. This had the potential to affect all residents requiring safe storage for personal food requiring refrigeration, 84 of 84 residents eating meals in the facility. The facility's policy for FOOD FROM OUTSIDE SOURCES, revised 10/2017 and reviewed 11/2023, included the following:POLICY: . Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. PROCEDURE: . 4. Residents may accept precooked foods from family members or other visitors. Foods may be brought for a specific resident and shared with other residents. b. Food brought to a resident by a family member or visitor may be stored in the food…
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.
- Potential for harm · F2026-06-30 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, Resident Council, the facility's policy for Daily Dumpster Monitoring, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's pest control service records; the facility failed to ensure there was not a build-up of greasy particles on the oil/grease refuse container, there was not a scattering of small particles of trash around the two dumpsters, and there was not a concentration of 30 to 40 flies in the dumpster area on 6/22/2026. This had the potential result of attracting rodents and flies, which could enter the facility to cause contamination and exposure to bites and maggots. This affected Resident Identifier (RI) #8, six of eleven residents in Resident Council, and had the potential to affect all residents in the facility, 88 of 88 residents. The facility's policy for Daily Dumpster Monitoring, dated 10/2006, included the following: . POLICY:Maintenance and Housekeeping staff will inspect all dumpsters each day to ensure that the surrounding area are free of debris and that the dumpster lids are closed .…
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.
- Potential for harm · Fdisputed · IDR2026-06-30 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from January 01, 2026 - March 31, 2026, to the Centers for Medicare & Medicaid Services (CMS).This failure affected one quarter of data reviewed during the survey. Findings Include: The PBJ report generated for the quarter of 01/01/2026 through 03/31/2026 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric .Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low .On 06/25/2026 at 3:45 PM, during an interview, the Administrator (ADM) stated she was responsible for submitting staffing data to CMS. The ADM said she did not know why low weekend staffing was triggered for the second quarter of 2026. She said she compiled the data for the report, sent the information to corporate and a third party company submitted the data to CMS. She said if incorrect data was submitted, CMS would not have accurate information concerning staffing.
- Potential for harm · E2026-06-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility policies titled, . TELS Maintenance Services Work Order and . Standard Method of Cleaning Checklist the facility failed to ensure a clean, safe, and homelike environment. Specifically, the facility failed to maintain resident care areas were in good repair and in a sanitary condition as evidenced broken tiles behind the commode in the bathroom belonging to Resident Identifier (RI) #34, RI #26, RI #72, and RI #1. Additionally, the bathroom belonging to RI #8, RI #57, RI #5 and RI #36 had a water damaged wall and dirty floors with urine observed on the floor.These failures affected RI #34, #26, #72, #1, #8, #57, #5, and #36. These failures had the potential to affect residents by exposing them to an environment that was not maintained in a clean, safe and homelike condition.Findings Include: A facility policy titled, TELS Maintenance Services Work Order with an effective date of 08/01/2022 documented: . PROCEDURE: 1. Whenever a need for maintenance services is detected…
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.
- Potential for harm · D2026-06-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 a policy titled, . Advance Directives and Refusal of Treatment the facility failed to ensure documentation regarding advance directives was complete and accurate. Specifically, the facility failed to maintain documentation that advance directives were discussed with Resident Identifier (RI) #81 and failed to ensure the advance directive documentation for RI #7 accurately reflected the resident's status. These failures had the potential to affect residents by preventing the facility from accurately identifying and honoring residents' advance directive decisions for 2 of 7 residents reviewed. Findings Include: A facility policy titled, . Advance Directives and Refusal of Treatment revised 11/2013 documented: PURPOSE:The resident has the right to refuse treatment, . to formulate an advance directive for management of his/her care.PROCESS:Prior to admission, the resident/sponsor will be provided information about the following:Advance Directives . Upon the resident's admission…
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.
- Potential for harm · D2026-06-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 and record review, the facility failed to ensure staff followed a physician's order to notify the medical provider when the Resident Identifier (RI) #89's blood glucose exceeded the ordered parameter of 250 mg/dL (milligrams/deciliter). Record review revealed a physician's order dated 03/07/2025 directing staff to check the resident's blood glucose four times daily before meals and at bedtime, document the results, and notify the medical provider for blood glucose readings below 70 mg/dL or above 250 mg/dL.Review of the Nurse Medication Administration History dated 03/01/2025 through 03/31/2025 revealed RI #89's had multiple blood glucose readings that exceeded the physician ordered notification and the medical provider was not notified. This deficient practice affected RI #89 one of four residents whose Medication Administration Record (MAR) was reviewed for physician notification during the survey. This citation was cited as a result of complaint/report number 463611. Findings include: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.
- Potential for harm · D2026-06-30 · tag F0644 — isolatedCoordinate 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 interview, record review, and review of the Alabama Department of Mental Health Preadmission Screening and Resident Review ( PASRR) Level I Screening and Determination documentation, the facility failed to ensure compliance with PASRR requirements for Resident Identifier (RI) #5 by failing to ensure completion of the required PASRR Level II Evaluation. Record review revealed RI #5 had diagnoses including Generalized Anxiety Disorder and Post-Traumatic Stress Disorder (PTSD). Despite the Level I screening dated 11/07/2024 identifying the need for a Level II Evaluation, the required evaluation was not completed until 01/23/2026. This deficient practice placed RI #5 at risk for not being comprehensively evaluated to determine the need for specialized services and support to address RI #5 mental health needs, as required under PASRR regulations. The facility's failure to ensure completion of the required PASRR Level II Evaluation affected RI #5, one of three residents reviewed for PASRR compliance.Findings…
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.
- Potential for harm · Dcited before2026-06-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interviews, observations, record review and review of a facility policy titled, Care Plans the facility failed to develop a comprehensive person-centered care plan to address the use of oxygen for Resident Identifier (RI) #1 and RI #35.This deficient practice affected RI #1 and RI #35 two of 30 residents whose care plans were reviewed. Findings Include:Review of a facility policy titled, Care Plans with a revised date of 09/2009 documented: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: . the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical needs, nursing and mental/psychological needs that are identified in the comprehensive assessment.PROCESS: . d) Comprehensive Plan of Care- within 7 days of the full assessments (admission, significant change, significant correction of prior full assessment and annual).1) 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.
Show the remaining 17 citations
- Potential for harm · D2026-06-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, record review and review of a facility policy titled, Incident and Accidents, the facility failed to provide evidence how it was determined Resident Identifier (RI) #91 acquired skin tears to the right upper shin, left knee, right buttocks, right hip, right knee and right lower shin on 11/05/2025. This deficient practice affected RI #91, one of two residents sampled for accidents. Failure of the facility to investigate to determine how RI #91 acquired the skin tears placed RI #91 at risk of acquiring further skin tears due to no interventions being implemented to reduce the risk of RI #91 acquiring skin tears. When incidents are not investigated, underlying root causes remain unknown.F689 was cited as result of the investigation of complaint/report number 2653290.Findings Include: Review of a facility policy titled, Incidents and Accidents, with a revised date of 10/2008, revealed the following: . STANDARD: Incidents are categorized as:Incident Type I-an incident is an occurrence that may…
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.
- Potential for harm · D2026-06-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, the facility failed to ensure a water pitcher containing thin liquids was not at the bedside of Resident identifier (RI) #11, resident at risk for aspiration, who was to receive nectar-thick liquids per physician's orders. These observations were made on three of seven days of the survey. This deficient practice affected RI #11, one of four resident's reviewed for nutrition/hydration, and had the potential to result in the resident consuming liquids of an unsafe consistency, placing the resident at increased risk for aspiration and choking. Findings Include: Review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, with a reviewed date of 12/2023 revealed the following:POLICY:The resident's diet is prescribed by the attending physician.PROCEDURE:1. The attending physician writes an order for regular or therapeutic diets . to be served to each resident, according to the resident's nutritional…
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.
- Potential for harm · D2026-06-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 a facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #1's oxygen tubing and RI #35's humidified water bottle was maintained in a manner to prevent contamination.Specifically: 1) RI #1's humidified water bottle was not dated when observed by the surveyor on 06/23/2026.2) RI #35's humidified water bottle was not dated when observed by the surveyor on 06/23/2026 and 6/24/2026. This deficient practice affected RI #1 and RI #35 two of four residents sampled for Respiratory Care. Findings Include:Review of a facility policy title, Oxygen Administration with an effective date of February 1, 2004, revealed the following: . PURPOSE: To administer high purity oxygen for the treatment of certain diseases or conditions. PROCESS: .11. Cannulas, masks and tubing should be changed weekly .1) RI #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis to include Pneumonia,…
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.
- Potential for harm · D2026-06-30 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure 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 record review, interview, and a policy titled . Behavior Management Program the facility failed to timely assess the behavior change and timely implement additional behavior interventions for Resident Identifier (RI) #90 a resident with a history of wandering behavior. Specifically: On 04/16/2025 RI #90 wandered into RI #57's room. RI #57 had a diagnoses of dementia with mood disturbance and staff had been made aware on 04/15/2025 that he/she did not want RI #90 in his/her room. Although staff were aware no interventions were in place to ensure RI #90 did not wander into RI #57's room. When RI #90 entered RI #57's room on 04/16/2025 RI #57 pushed RI #90 out of the room causing him/her to fall and sustain a fracture to the left maxillary sinus wall and lateral border of the left orbit. This deficient practice affected one of two residents reviewed for behavior health. This deficiency was cited as a result of complaint #463612. Findings include: On 04/16/2025 at 1:16 PM the Alabama State Survey Agency…
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.
- Potential for harm · D2026-06-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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, Oral Medication Administration, the facility failed to ensure the medication nurses initialed on Resident Identifier (RI) #54's Medication Administration Record (MAR) that RI #54's Hydrocodone-Acetaminophen (Norco) 10/325 mg (milligram) and Pregabalin (Lyrica) 200 mg, both narcotic medications, had been administered to RI #54 on 05/02/2026 at 6:00 AM; and on 05/25/2026 at 6:00 PM.This deficient practice affected RI #54, one of four residents whose MARs was reviewed for medication administration. When nurses do not initial or document on the MAR immediately after administering a medication, another nurse may assume the resident did not receive the medication and administer a second dose, which could place the resident at risk of a dangerous overdose.Findings Include:Review of a facility policy titled, Oral Medication Administration, with an effective date of 02/01/2004 revealed the following: PURPOSE:To administer oral medications in 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.
- Potential for harm · D2026-06-30 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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, record review, interviews and review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, the facility failed to ensure Resident Identifier (RI) #3 was served double portions of proteins as a part of the resident's therapeutic diet.This deficient practice affected RI #3, one of four residents that were reviewed for nutrition and was observed during the breakfast and lunch meals on 06/24/2026. RI #3 not receiving his/her double portions of protein placed RI #3 at risk of a decrease in his/her protein levels which may lead to malnutrition, weight loss and muscle wasting. Findings Include: Review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, with a reviewed date of 12/2023 revealed the following:POLICY:The resident's diet is prescribed by the attending physician. PROCEDURE:1. The attending physician writes an order for regular or therapeutic diets . to be served to each resident, according to the resident's nutritional and medical requirements and/or limitations and preferences…
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.
- Potential for harm · Ddisputed · IDR2026-06-30 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and a document titled ARBITRATION AGREEMENT AND WAIVER OF JURY TRIAL the facility failed to ensure arbitration agreements were implemented in a manner that protected resident rights. Specifically, the agreement required residents or families to submit written notice to rescind the arbitration agreement within 30 days and did not allow the resident to rescind the agreement verbally. This failure had the potential to affect all residents who executed arbitration agreements with the facility.Findings Include: An agreement titled ARBITRATION AGREEMENT AND WAIVER OF JURY TRIAL documented: . C. Right Not To Sign And To Rescind This Agreement . You are NOT required to sign this agreement in order to be admitted to, or continue to receive care at, the facility. You are permitted to rescind this Agreement within the first 30 days after you sign this Agreement. To do so, send a signed letter to the Facility at [ADDRESS.] The letter should include your full name, address, and the last four digits of your social security number, and should state that you are exercising your…
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.
- Potential for harm · D2023-07-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observations, interviews, and review of the facility NURSING HOME RESIDENT RIGHTS, the facility failed to ensure Resident Identifier (RI) #77 received their meal at the same time as their roommate, this was observed on 7/16/23 at the supper meal and 7/17/23 at the breakfast meal. This affected one of 24 sampled residents. Findings Include: A review of the facility NURSING HOME RESIDENT RIGHTS revealed Residents of Nursing Homes have rights that . promote and protect the rights of each resident and stresses individual dignity . Right to a Dignified Existence * Be treated with consideration, respect, and dignity, . RI # 77 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Dementia. A review of RI #77's Significant change Minimum Data Set (MDS) with an Assessment Reference Date of 6/16/23 revealed RI #77 was severely impaired with decision making and was total dependent on staff for eating. RI #77 was unable reply to the surveyor. On 7/16/2023 at 5:45 PM, RI #77's roommate…
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.
- Potential for harm · D2023-07-19 · tag F0641 — isolatedEnsure 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, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #40's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was coded accurately to reflect RI #40 did not receive an antidepressant, medication during this assessment period. This deficient practice affected RI #40, one of 23 sampled residents whose MDS assessments were reviewed. Findings Include: RI #40 was admitted to the facility on [DATE] with a diagnosis of Mood Disorder due to known psychological condition with Depressed Features. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, revealed the following: . SECTION N: MEDICATIONS . N0410C, Antidepressant: Record the number of days an antidepressant medication was received by the resident at any time during…
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.
- Potential for harm · D2023-07-19 · tag F0645 — isolatedPASARR 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 interview, a facility policy titled, Pre-admission Screening for Mental Retardation and Mental Illness, and review of Resident Identifier (RI) #57's PASARR (Preadmission Screening and Resident Review), the facility failed to ensure RI #57's PASARR was accurately marked with an admission diagnosis of Major Depression, which would have indicated a Level II. The facility further failed to resubmit a Level I or II when RI #57 was readmitted to the facility with a diagnosis of Psychosis. This affected one of one resident sampled for PASARR. Findings Include: A review of an undated facility policy titled Pre-admission Screening for Mental Retardation and Mental Illness revealed, . PURPOSE: To ensure that individuals with mental retardation and mental illness receive the care and services they need, in the most appropriate setting. On 7/17/2023 at 5:09 PM a review of RI #57's PASARR revealed only a Level I, also no diagnosis were marked. RI #57 was admitted to the facility on [DATE] and readmitted on [DATE]. 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.
- Potential for harm · Dcited before2023-07-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 medical record review, interviews, and a facility's policy tilted, Care Plans the facility failed to ensure a care plan for depression was developed for RI (Resident Identifier) #72 a resident with a diagnosis of depression and a smoking care plan was developed for RI #74, a resident who was identified as a smoker. This deficient practice affected two of 23 sampled residents whose care plans were reviewed. Findings Include: A review of a facility's policy titled, Care Plans with a revised date of 09/2009 documented: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulation, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . RI #72 was admitted to the facility on [DATE] and readmitted to the facility…
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.
- Potential for harm · D2023-07-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, and staff interview the facility failed to ensure a splinting device for Resident Identifier (RI) #3's hand was in place on 7/18/2023 to prevent decreased Range of Motion (ROM). This deficient practice affected RI # 3 one of two residents sampled for position/mobility concerns. Findings Include: Resident Identifier (RI) #3 was readmitted to the facility on [DATE] with diagnoses to include Intracerebral hemorrhage and muscle weakness. A review of RI #3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/25/2023 revealed RI #3's Brief Interview for Mental Status (BIMS) score was 10, indicating moderately impaired. Section G of the MDS, for Functional Status documented RI #3 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper and lower extremity impairment on one side. A review of RI #3's Physician Orders documented . 2/6/2023 .RESIDENT PARTICIPATION TO HAVE PROM (Passive Range of Motion)…
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.
- Potential for harm · Fcited before2019-10-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of facility policies titled, MACHINE WAREWASHING, SAFETY GUIDELINES, FOOD SERVICE OPERATION STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE, OF FOOD and STORAGE OF FROZEN FOOD, the facility failed to ensure: 1. silverware in bags and in a silver ware holder were not wet at the tray line; 2. bowls were not wet and chipped; 3. new food was not poured over old food; and 4. chicken wings were labeled in the freezer. This had the potential to affect 88 of 88 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, MACHINE WAREWASHING with a reviewed date of 2/15, revealed: POLICY All dishes and utensils will be washed and sanitized after each use. PROCEDURE: .4. Wash dishes according to machine direction.d. All dishes, glassware, and silverware are air dried. On 10/9/2019 at 10:50 a.m., the surveyor observed a dietary worker bagging silverware ready to go out to the residents. A total of five bags had wet spoons, forks and knives. The surveyor observed wet utensils in a silverware…
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.
- No harm found · Cdisputed · IDR2026-06-30 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, the facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, and a certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida; the Dietary Supervisor in charge of the facility's Food Service Department/Dietary Department did not meet minimum qualifications as a director of food and nutrition services. This had the potential of affecting 84 of 84 residents receiving meals from the facility's Food Service Department/Dietary Department while it was under the direction of an unqualified individual. Findings Include: The facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, dated 5/2003, included the following: . General Purpose: To assist in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe 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.
- No harm found · Cdisputed · IDR2026-06-30 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, the Resident Council Meeting, the facility's MEAL SERVICE TIMES, and the facility's policy for FREQUENCY OF MEALS; the facility failed to ensure cart deliveries of meals were not scheduled to exceed 14 hours between service from Dinner to Breakfast for Rehab/West Hall, North Hall, South Hall, and Meal Assist. This had the potential to affect 84 of 84 residents receiving meals at the facility.Findings Include: The facility's policy for FREQUENCY OF MEALS, last revised 6/2017 and last reviewed 12/2023, included the following: . POLICY: . There is no more than a fourteen (14) hour span between a substantial evening meal and breakfast. The facility's MEAL SERVICE TIMES, undated, included the following: Breakfast Cart 1 - Rehab/West Hall 7:15 AMCart 2 - North Hall 7:30 AMCart 3 - South Hall 7:40 AMCart 4 - Meal Assist 8:00 AMDinnerCart 1 - Rehab/West Hall 5:00 PMCart 2 - North Hall 5:15 PMCart 3 - South Hall 5:30 PMCart 4 - Meal Assist 5:45 PM. Resident Council met at 10:00 AM on 06/24/2026 with eleven residents in attendance. During this meeting, the Resident Council…
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.
- No harm found · B2026-06-30 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and a review of the facility's Resident Rights the facility failed to ensure residents received mail in a timely manner by not delivering mail received on Saturdays. This failure had the potential to affect all residents who received mail at the facility by delaying access to correspondences and other mailed information. Findings Include: A review of the Resident Rights with a revised date of 01/2017, revealed: . SUBJECT: Residents Rights .15. The Resident has the . right to access private communication of all kinds, . On 06/23/2026 at 10:00 AM a Resident Council Meeting was held. The eleven residents in the meeting stated that they did not receive mail on the weekend. When the residents were asked why they did not receive mail on Saturday, residents stated that there was no one to pass the mail out. On 06/25/2026 at 11:26 AM an interview was conducted with the Social Services Director (SSD). She was asked the process for residents to receive mail on Saturday. She stated she was not sure, and it was handled through the business office. She also stated that no one…
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.
- No harm found · B2026-06-30 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide Resident Identifier (RI) #80 and RI #80's representative a written notice of transfer when RI #80 was transferred to the hospital on [DATE] and 03/16/2026. This deficient practice affected RI #80, one of three residents reviewed for hospitalization. Failing to provide a written transfer notice when a resident is transferred to the hospital violates the residents right to return to their nursing facility after a hospital stay. Without a written notice documenting the specific medical reason for the transfer, the facility could discharge the resident and fill their bed while the resident is in the hospital. RI #80 was originally admitted to the facility on [DATE] and had a last readmit on 03/20/2026. RI #80 had diagnoses to include Epilepsy, Cognitive Communication Deficit, Hypertension and Chronic Kidney Disease. A review of RI #80's Progress note dated 03/08/2026 revealed around 9:45 AM, RI #80 was yelling out in his/her room and was very…
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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BALL HEALTHCARE SERVICES — 9 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.6 | -1.6 vs chain |
| Staffing | 3 of 5 | 3.2 | -0.2 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 8 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BALL, CLARENCE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 100% | since 07/01/2003 |
| HALL, MATTHEW | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 10/01/2014 |
| CHAMBLISS, TIFFANY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/26/2023 |
| HOLT, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2021 |
| BALL HEALTHCARE - MACON, INC. | Organization | ADP OF THE SNF | — | since 06/06/2003 |
| BALL HEALTHCARE SERVICE, INC | Organization | ADP OF THE SNF | — | since 04/09/2025 |
| INPATIENT CONSULTANTS OF ALABAMA, INC | Organization | ADP OF THE SNF | — | since 04/01/2021 |
| JOHNSON, ANGELA | Individual | ADP OF THE SNF | — | since 02/27/2024 |
CMS files one row per role, so the 12 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 85% 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 21% 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
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.
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 015112. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-30, 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.