Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntsville Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with documented elopement risk, a guardian, and a Wander Guard was not physically checked when staff realized the resident was missing, and the resident was later found by police lying in a road with seizures and altered mental status after leaving the facility unnoticed. Another resident with wandering and cognitive concerns was observed near a busy roadway after leaving unsupervised, with incomplete sign-out documentation and no elopement reassessment. The facility also failed to control smoking safety for a resident with a history of arson and fire-setting and for another resident who smoked in a room with a blind roommate, despite policies requiring supervised smoking and secure control of smoking materials.
Failure to Manage Unsafe Behaviors and Behavioral Health Needs: A resident with dementia, schizophrenia, and a history of fire-setting repeatedly smoked in undesignated areas and in the building, while another resident with mood disorder, nicotine dependence, and TBI repeatedly smoked in the room and bathroom and kept smoking paraphernalia in the room. The facility also failed to monitor residents with elopement risk, allowing one resident to wander unsupervised and elope, another to leave the building unsupervised multiple times and nearly be struck by a vehicle, and a third resident with a history of aggression to physically assault other residents.
A resident with moderate cognitive impairment and a care plan addressing refusals of care was forcibly held down by an RN and CNA after refusing incontinent care multiple times. During the interaction, the resident became physically aggressive, but staff continued the care, with witness statements describing the RN directing that the resident had to be changed. The resident later reported being held down, having arms grabbed, clothing ripped off, and being washed with a cold rag; bruising, wrist redness, hand discoloration, soreness, and emotional distress were documented.
Failure to Assess and Treat Worsening Pressure Injuries: Two residents with high pressure injury risk had new skin breakdown that was not promptly assessed or treated by the treatment nurse. One resident’s buttocks/sacral excoriation progressed to an unstageable wound with foul odor, drainage, and necrotic tissue, while another resident’s buttocks and sacral open areas were not evaluated or placed on treatment until they later became unstageable and then stage III/IV pressure injuries. Staff interviews confirmed the wounds should have been documented, measured, and monitored earlier.
Staff did not follow the posted lunch menu for a puree entree and fruit side. A Dietary Manager used a #12 scoop for Puree Beef Stroganoff and stated the puree version did not include noodles, even though the recipe called for the dish to be served over rice or noodles and the diet guide listed a 6 oz portion. Staff also used a #16 scoop for Sliced Strawberries instead of the 1/2 cup portion listed on the diet guide. The RD confirmed the menu was not being followed and that the portions served were incorrect.
Failure to Protect Residents from Resident-on-Resident Physical Abuse: A resident with documented aggressive behavior repeatedly assaulted other residents after wheelchair contact in the dining room and hallway. The resident yelled, cursed, grabbed hair and clothing, hit residents in the face and head, and pulled one resident from a wheelchair, causing scratches, discoloration, and other minor injuries. Facility records described a pattern of monthly physical altercations, but no effective supervision or behavior-management approaches were included in the care plan.
Hot puree lunch items were served at an improper temperature during trayline service. A test tray showed that Puree Beef Stroganoff and Puree [NAME] Beans were not hot, and the CDM agreed the items did not melt butter/margarine. Prior Resident Council minutes and a grievance also documented complaints that food was cold on the halls and that chili came out cold and was not heated up.
The facility failed to develop and implement policies and procedures for residents independently signing themselves out and leaving without supervision. The CQA Director stated nurses ask the resident’s expected return time, check the elopement book, and may send medication, but she was unaware of a specific policy for assessing whether a resident could sign out independently or with supervision. She also stated the decision would rely on resident rights, the MDS, the elopement assessment, and BIMS, and that a refusal to sign out could be treated as AMA if the BIMS score was high enough.
QAPI failed to identify all causal factors related to two elopements and smoking noncompliance involving two residents. The committee did not determine all contributing factors or what actions were needed to prevent further resident safety concerns. The facility’s policy required systematic analysis and root cause review, but the investigation showed the events involved a resident accessing clippers and cutting a screen, a window that was not properly secured, and smoking concerns tied to the absence of a locked container for smoking materials.
A resident with CHF and HTN, who was cognitively intact and care planned for fragile skin, was held on his/her side by two CNAs during ADL care after repeatedly saying not to touch him/her. One CNA reported the resident was combative and tried to kick and hit staff, while the other said the resident said, “Don’t touch me,” as she held the resident’s shoulder and leg and blocked hits. The resident’s rep later reported bruising to both hands, and the resident said the prior attempt at care hurt.
A resident with dementia, schizophrenia, bipolar disorder, and recent agitation was sent to a psych eval after yelling, cursing, and slamming doors in a shared room with another resident. When the resident returned, he/she was placed back in the same room and ordered q15-min checks, but staff could not locate documentation of those checks. The roommate stated the resident’s behavior scared him/her, and the ADM later said she did not know why the resident was returned to that room.
Failure to Immediately Report Alleged Verbal Abuse: The facility did not ensure an allegation of verbal abuse involving two residents was reported to the ADM immediately, as required by policy. One resident with dementia-related diagnoses became agitated, yelled, cursed, and slammed doors while in a room with a roommate who had muscle weakness and spina bifida. The charge nurse reported the agitation to the unit manager, but the ADM was not aware of the incident until later, and stated it should have been reported immediately.
A resident admitted after right leg surgery and fracture reported significant pain, but the ordered oxycodone was not available when first needed. Staff did not give pain medication at admission, and when the medication was later available, the resident received only one tablet despite a severe pain rating that called for four tablets. The resident later called 911 and went to the hospital because of pain.
A resident admitted with a right fibula fracture and ankle discoloration did not have ordered Oxycodone 5 mg available when pain was requested because the medication orders were not faxed to the pharmacy in time. The admissions process involved sending the discharge paperwork and medication list, but the MR nurse said she did not fax the orders due to a family emergency and was unsure when they were sent. An LPN found the pain medication was not in the stat box, and the CP stated pain medication should always be available and that the backup pharmacy could be used if needed.
Improper Handling of Clean Laundry: Laundry staff was observed folding clean sheets in the clean laundry area while the sheets touched the front of the staff member’s clothing, and the staff member was not wearing an apron. The facility policy stated linens must be handled in a manner that prevents the transmission of microorganisms, and both the ESD and Interim DON identified the situation as an infection control concern.
Incomplete Daily Nurse Staffing Postings: The facility failed to post complete nurse staffing information on the daily staffing form. Surveyors observed missing night shift entries on multiple days and a missing evening shift entry on one day, with the census also omitted from the postings. The IDON stated the scheduler and a chosen night shift charge nurse were responsible for updating the form and confirmed the required staffing details and census were not fully entered.
Failure to Supervise Elopement Risks and Enforce Smoking Safety
Penalty
Summary
The facility failed to ensure residents at risk for elopement were supervised so their whereabouts were known and they remained free from accident hazards. RI #106 had diagnoses including encephalopathy, schizoaffective disorder, expressive language disorder, adjustment disorder with mixed anxiety and depressed mood, mood disorder due to a known physiological condition with manic features, and other speech disturbances. The resident also had a court-appointed guardian, an elopement evaluation that identified elopement risk, a care plan with interventions for exit-seeking behavior, and an order for a Wander Guard device to be secured to the ankle and checked every shift. On the morning of the incident, staff found the resident was not in the room, the window was raised, and the resident was not in the building. Staff interviews showed the resident had last been seen around 2:00 AM, but when the resident was not found around 4:00 AM, staff did not physically check the resident or determine the resident’s whereabouts. The nurse later acknowledged she documented the Wander Guard as checked even though she had not actually verified it. RI #106 was later found by police lying in the middle of a road near an intersection adjacent to an interstate and U.S. highway, nearly struck by a patrol car. EMS documented seizures while the resident was being evaluated, and the resident was transported to the hospital and later transferred to an acute care psychiatric facility. Hospital records documented altered mental status, expressive aphasia, right hemiplegia, encephalopathy, seizures, and inability to provide identifying information. The facility investigation also noted the window screen appeared cut, the window was pushed up, and nail clippers were found on the bed. The maintenance director stated the door alarm system had not been functioning properly and that the alarm sensitivity and volume had been lowered. The facility also failed to ensure RI #121 was supervised in a manner that kept the resident’s whereabouts known. RI #121 had diagnoses including end stage renal disease, dependence on renal dialysis, hypertensive heart disease, cognitive communication deficit, difficulty walking, and other abnormalities of gait and mobility. The resident had a prior elopement evaluation that found minimal risk and no care plan, despite documentation of wandering and behavioral concerns. Records showed the resident signed out of the facility on one occasion with incomplete documentation, and staff later observed the resident unsupervised on the front porch and then near a busy roadway. Staff reported the resident was nearly struck by employees’ vehicles and was found standing near the road wearing earphones and unable to hear staff calling out. Interviews confirmed no elopement reassessment was completed after the resident left the facility unsupervised. The facility further failed to monitor smoking safety for RI #33 and RI #109. RI #33 had diagnoses including dementia with mood disorder and paranoid schizophrenia, a behavior plan for noncompliance with smoking and setting fires, and a documented history of arson and attempted fire-setting. Despite this history, the resident was observed with cigarettes and lighters and was later seen burning an orange juice container in the smoking area. RI #109 was the subject of an anonymous complaint that the resident smoked in a room with a blind roommate, and the investigation determined the resident was noncompliant with the facility smoking policy and procedures. The report states these deficiencies were cited as immediate jeopardy and substandard quality of care under F689, and also includes separate actual-harm findings related to unsafe mechanical lift transfers involving RI #103 and RI #74.
Failure to Manage Unsafe Behaviors and Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure behavioral health care and services were provided for residents with known unsafe behaviors, including unsafe smoking, wandering, elopement risk, and physical aggression toward other residents. The report states the facility did not implement a behavior management process to identify, evaluate, and address behaviors affecting resident safety, and did not recognize the need for adequate supervision and monitoring of residents with unsafe behaviors. The Immediate Jeopardy was cited under F740 Behavioral Health Services and was identified as beginning on 03/30/2024. Resident #33 had diagnoses including Dementia with Moderate Mood Disturbance, Insomnia due to other mental disorders, Mental Disorder NOS, and Paranoid Schizophrenia, and had a BIMS score of 15 of 15. The resident’s behavior management care plan addressed noncompliance with smoking and setting fires, with interventions including 1:1 supervision, re-education on smoking policy, observation and documentation of target behaviors, diversional activities, and behavior medications as ordered. Progress notes and staff interviews documented repeated unsafe smoking-related behaviors, including smoking in undesignated areas, smoking in the building, possession of cigarettes and lighters, and a history of starting fires. Staff described that when cigarettes or lighters were found, they were taken away, and the medical director stated she was aware of the smoking and aggression but not that the resident was a fire starter. Resident #109 had diagnoses including Mood Disorder due to Psychological Condition with Depressive Features, Paraplegia, Nicotine Dependence, and Personal History of Traumatic Brain Injury, and also had a BIMS score of 15 of 15. The resident was care planned for verbal behavioral symptoms, nicotine addiction, and smoking outside designated areas, with an approach to observe for need for 1:1 smoking supervision. Progress notes documented repeated smoking in the room and bathroom, strong cigarette odor, cigarette butts and smoking paraphernalia in the room, and marijuana odor in the room. Staff interviews confirmed that the resident continued to smoke in the room and that no new interventions were put in place beyond education on the smoking policy. Resident #106, who had a history of elopement risk, wandered the facility unsupervised during the day and at night and eloped on 04/14/2026 without the facility being aware. Resident #121, who had a history of elopement risk, noncompliance with care/treatment, and confusion, left the building unsupervised on 04/05/2026 and 04/10/2026, and eloped again on 04/11/2026, nearly being struck by an employee’s vehicle. The facility was aware of the earlier instances because the resident was allowed to leave unsupervised. The report also states the facility failed to manage Resident #116’s pattern of abusive behavior toward other residents, including swinging at, hitting, and pulling other residents to the floor when wheelchairs bumped into each other. Investigative files documented physically abusive incidents involving multiple residents on several dates, and the deficiency affected five sampled residents.
Physical restraint during refused care
Penalty
Summary
Freedom from physical restraint was not maintained when staff forcibly held a resident down after repeated refusals of incontinent care. The resident had diagnoses including myopathy and essential hypertension, and a recent MDS documented a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan noted behavioral symptoms such as refusing care, becoming combative during care, and frequent refusal of incontinent and hygiene care, with interventions directing staff to allow choices, avoid arguing, approach later if combative, and provide peri-care as the resident would allow. On the day of the incident, the resident refused care on multiple occasions. CNA #64 reported that she attempted to check the resident’s brief, was refused, and returned twice more with the same result before informing RN #63. RN #63 then directed CNA #64 to gather supplies and return to assist with care. During the attempt to provide care, the resident became physically aggressive, and staff continued with the interaction rather than stopping after the refusals. Witness statements described RN #63 directing continued care and stating the resident had to be changed, while CNA #64 stated she followed RN #63’s instructions and believed the resident could no longer refuse care. The resident reported that RN #63 and CNA #64 came into the room, held him/her down, grabbed his/her arms, ripped off clothing, and washed him/her with a cold rag. The resident’s daughter reported being told that staff held the resident down, and a police report documented visible fresh bruising to the wrists and hands. A clinical assessment found bilateral bruising and redness to the wrist area, discoloration to both hands, soreness to touch, and emotional distress with tearfulness when recalling the event. RN #63 denied restraining the resident and stated she was guarding herself and CNA #64 from the resident’s aggressive actions, but the investigation substantiated the incident as physical abuse.
Failure to Assess and Treat Worsening Pressure Injuries
Penalty
Summary
The facility failed to provide ongoing skin assessments and timely wound evaluation for two residents with identified skin breakdown, resulting in pressure injuries being recognized only after they had progressed to advanced, unstageable wounds. The deficiency was cited under F686, Treatment/Services to Prevent/Heal Pressure Ulcers, and was associated with Immediate Jeopardy findings involving Resident Identifier #108 and Resident Identifier #51. The report states that the facility did not identify or reassess worsening skin conditions early enough, and that treatment changes were not initiated when new open areas or excoriation were first observed. For Resident Identifier #108, staff noted excoriation and redness to the buttocks/sacral area, but the area was not fully assessed with measurements, drainage, or odor documentation at that time. An order was obtained to clean and cover the area three times weekly, yet the area was not reassessed or changed until it was later documented as an unstageable wound measuring 5 cm by 4.5 cm with 1 cm depth, seropurulent drainage, foul odor, and necrotic tissue. The resident had diagnoses including Parkinsonism, contracture, autistic disorder, muscle weakness, and aphasia, and was identified as high risk for pressure injuries on Braden Scale and MDS review. Interviews with nursing staff and the CRNP indicated the wound had progressed from a skin shear/excoriation to a much larger, deeper wound over time, and staff acknowledged that the wound should have been documented and treated earlier. For Resident Identifier #51, staff documented two small open abrasions and several red areas on the lower right buttocks, but the treatment nurse did not assess the area and preventive treatment was not initiated at that time. The wound was later identified as an unstageable pressure ulcer with slough and drainage, measuring 5 cm by 4 cm, and was subsequently documented as stage IV. The resident also had several open areas on the coccyx/sacrum after readmission from the hospital, but the treatment nurse did not document an initial assessment or start treatment until the areas were later identified as a pressure ulcer, then unstageable, and later stage III. The resident’s diagnoses included osteomyelitis, type 2 diabetes with diabetic neuropathy, and pressure ulcer of unspecified buttocks, and the record showed the resident was at risk for pressure ulcers. Interviews with nursing staff and the CRNP confirmed that newly identified open areas should have been assessed, measured, documented, and treated promptly, but that did not occur in these instances.
Menu Portions Not Followed for Puree Entree and Fruit Side
Penalty
Summary
The facility failed to follow the Spring/Summer 2026 Week 3 menu for Wednesday lunch by not providing the portion sizes listed for Puree Beef Stroganoff and Sliced Strawberries. The facility’s policies stated that menus should meet residents’ nutritional needs, be prepared in advance, be followed, and include portions stated in ounces or measurements. The Puree Foods policy also stated that pureed food items should be the same as those served on the regular menu, and the Food Preparation Guidelines required menu items to be prepared according to written menus and recipes. During the lunch trayline observation, the Dietary Manager was acting as the AM dietary lead. Puree Beef Stroganoff was portioned using a #12 scoop, which measured 2 2/3 oz, and a normal puree plate was observed containing one #12 scoop of Puree Beef Stroganoff, one #8 scoop of Puree beans, and one #12 scoop of Puree bread. The facility’s Beef Stroganoff recipe directed that the dish be served over rice or noodles, but the Dietary Manager stated the puree Beef Stroganoff was only the beef and gravy and did not include noodles. The Production Sheet used by staff did not include puree diet portion information. Sliced Strawberries were also portioned incorrectly. The diet guide specified 1/2 cup for the regular menu, but staff used a #16 scoop, which measured 2 oz, to serve the strawberries. The AM Dietary Aide said she used the diet guide and had not referred to the scoop chart, and she did not know the scoop size until it was pointed out. The Regional Dietary Consultant, a Registered Dietitian, stated that the correct serving for puree Beef Stroganoff should have been 6 oz of meat and gravy mixed with pasta using a #5 scoop, and that a #8 scoop should have been used for the 1/2 cup strawberries. The consultant stated the menu was not being followed and that four residents were receiving a puree diet and 75 residents were eligible to receive the strawberries.
Failure to Protect Residents from Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by a resident with a documented pattern of aggressive behavior toward others when wheelchairs bumped together. Resident #116 had diagnoses including Peripheral Vascular Disease, Mood Disorder, and Intellectual Disabilities, and a quarterly MDS documented a BIMS score of 15, indicating intact cognition. The resident’s care plan identified that the resident was aggressive with other residents and had a history of hitting and fighting, but it did not include approaches to guide staff in supervising or de-escalating the resident to prevent abuse of others. On 12/24/2024, during an activity in the dining room, Resident #115 accidentally bumped into Resident #116’s wheelchair while backing out after getting a soda. Resident #116 yelled and cursed, then the two residents hit each other in the face. The facility’s investigation documented pink discoloration to Resident #115’s left cheek and a small cut to the bridge of Resident #116’s nose, and the investigator concluded that resident-to-resident physical abuse was confirmed. The investigative file also noted there were no staff members who witnessed how the physical abuse started. On 08/09/2025, Resident #81 accidentally bumped Resident #116’s wheelchair near the dining room entrance, after which Resident #116 swung at Resident #81, grabbed the resident’s shirt, and the two residents struck each other. Resident #81 had a small discoloration under the right eye and redness to the left side of the neck. On 10/08/2025, Resident #115 again accidentally bumped Resident #116’s wheelchair, and Resident #116 grabbed Resident #115’s hair, pulled the resident out of the wheelchair, and would not let go as both residents fell to the floor and hit each other. Resident #115 had scratches to a finger and forehead, and Resident #116 had a red eye, surrounding discoloration, and a raised area to the forehead. On 10/27/2025, Resident #116 bumped into Resident #21’s wheelchair, tried to grab the resident’s hair, and then hit the resident in the side of the head with a fist. The facility’s records and interviews described Resident #116 as having combative behavior and monthly physical altercations, but the report states there were no recommendations for supervision or monitoring to prevent further abuse of residents.
Hot Puree Lunch Items Served at Improper Temperature
Penalty
Summary
The facility failed to ensure hot food was served hot at lunch on Wednesday, 04/22/2026. Based on observations of the lunch trayline, a test tray, interviews, the Resident Council Minutes, the Grievance Log, and the facility’s policies for Food Preparation Guidelines and Food Cooking and Serving Temperatures, the Puree Beef Stroganoff and Puree [NAME] Beans on the test tray were not hot. The facility’s policies stated that food should be served attractively at proper temperatures and be palatable, attractive, and at the proper temperature based on the type of food. During the lunch service, the residents’ trayline was observed at 11:50 AM. A test tray was requested at 12:50 PM for the last tray on the last cart, and the last cart was loaded beginning at 1:09 PM. The test tray was prepared at 1:20 PM, the last cart left the kitchen at 1:21 PM, and residents on the North Hall were served by 1:25 PM, with the last tray served at 1:29 PM. When the test tray was evaluated at 1:31 PM with the Clinical Certified Dietary Manager, the Puree Beef Stroganoff and Puree [NAME] Beans did not melt butter/margarine, and the Clinical Certified Dietary Manager agreed these items were not hot. The Resident Council Minutes and Grievance Log also documented prior complaints that food was cold on the halls and that chili came out cold and was not heated up.
Lack of Policy for Residents Signing Themselves Out
Penalty
Summary
The facility failed to ensure policies and procedures were developed and implemented regarding residents independently signing themselves out of the facility and leaving without supervision. During an interview, the Corporate Compliance Officer/Quality Assurance Director stated that when residents sign themselves out, a nurse asks their expected return time, checks the elopement book to confirm the resident is not a risk, and may administer or send medication if needed. She also stated that if the resident did not return, the nurse would follow up by calling to determine the return time. When asked about a policy for assessing whether residents could sign themselves out independently or with supervision, she was unaware of a specific policy and stated that resident rights included the ability to sign out if capable. She further explained that residents who could sign out independently would be presumed capable of managing ADLs and would be determined by the MDS and Elopement Assessment. She stated that if a resident refused to sign out, it would be considered AMA if the BIMS score was sufficiently high, and that the facility would consult the MD and refer the case to DHR if a resident left and the facility considered it an inappropriate placement.
QAPI Committee Failed to Fully Analyze Elopement and Smoking Noncompliance Events
Penalty
Summary
The facility’s QAPI committee failed to identify all causal factors related to two elopements involving RI #106 and RI #121 and smoking noncompliance involving RI #33 and RI #109. The report states that these deficient practices were identified through investigations of facility-reported incident/complaint/report numbers 447450, 2983895, and 2621001, and that the committee did not determine all of the factors contributing to the events or what corrective actions were needed to prevent further resident safety concerns. A review of the facility’s QAPI policy showed that the committee was expected to use systematic analysis, including root cause analysis or PDSA, to identify improvement opportunities and understand how to improve them. During interview, the Regional Administrator stated that the facility had recognized issues related to elopement and smoking noncompliance, and described the events as involving a resident accessing clippers and cutting a screen, with a window not properly secured, and smoking concerns related to the absence of a locked container for smoking materials. The report also notes that the facility had identified pressure injury concerns, but the cited deficiency focused on the QAPI committee’s failure to fully analyze the elopements and smoking noncompliance events and to determine all causal factors.
Resident’s Refusal of Care Not Honored During ADL Assistance
Penalty
Summary
The facility failed to protect a resident’s right to refuse care and treatment when two CNAs held the resident on his/her side to provide care after the resident repeatedly told them not to touch him/her. The resident was admitted with systolic congestive heart failure and essential hypertension, had a BIMS score of 14 on the admission MDS indicating cognitive intactness, and was care planned for ADLs with fragile skin, with interventions to use gentleness and allow choices when possible. The resident’s care plan and the facility’s Resident Rights policy both documented the resident’s right to refuse treatment. During the incident, CNA #75 reported the resident was combative, cursing, and trying to kick and hit staff while being changed, and CNA #76 stated the resident said, “Don’t touch me,” while she held the resident’s shoulder and leg and blocked the resident from hitting her as the resident continued to strike at staff. The resident’s representative later reported bruising and discoloration to both hands that had not been present the prior day, and the resident stated that the other night staff had tried to change him/her and it hurt, so he/she slapped at them. The facility investigative file also documented discoloration to both hands and fingers, with the left hand more discolored.
Failure to Protect Roommate After Psychiatric Return
Penalty
Summary
The facility failed to protect Resident Identifier (RI) #114 from RI #19 after RI #19 returned from the hospital’s psychiatric unit. RI #19 had been sent out on 08/21/2025 after becoming agitated in the shared room with RI #114, where he/she was yelling, cursing, and slamming doors. RI #114 stated that RI #19’s actions scared him/her. The facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation stated that the facility would take reasonable measures to protect a resident, including separating the resident from the person suspected of abuse. RI #19 had diagnoses including Alzheimer’s disease with late onset, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, adjustment disorder with depressed mood, schizophrenia, and bipolar disorder. RI #19’s MDS assessment showed a BIMS score of 14, indicating intact cognition. RI #114 had diagnoses including muscle weakness and spina bifida, and the MDS assessment showed a BIMS score of 15, indicating intact cognition. After RI #19 returned to the facility at 3:01 AM on 08/22/2025, the progress note stated that RI #19 was alert and oriented with slight confusion, denied suicidal or homicidal ideation, and was placed on q15-minute checks. RI #114 stated that RI #19 was later placed back in the same room and that he/she did not remember staff checking on RI #19 every 15 minutes. RN #49 stated that RI #19 was placed back in the same room he/she came from and that the CNA staff had primary responsibility for q15-minute checks, but she did not know where those checks were documented. The Administrator stated she did not know why RI #19 was placed back in the room with RI #114 and later said she did not think it was a good idea for RI #19 to return to that room. A signed statement from the Regional Administrator noted staff were unable to locate q15-minute documentation showing RI #19 was monitored and RI #114 was protected from further outburst.
Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving two residents was reported to the Administrator immediately. A facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation stated that each employee has an obligation to immediately report any incident or allegation that could constitute abuse or neglect to the Administrator, DON, or Department Supervisor, and that the Administrator must be notified of any unusual situation immediately. The incident involved Resident Identifier #19 and Resident Identifier #114 in a resident room at 7:45 PM on 08/21/2025. RI #19, who had diagnoses including Alzheimer's disease with late onset, dementia, psychotic disturbance, mood disturbance, anxiety, adjustment disorder with depressed mood, schizophrenia, and bipolar disorder, was reported to have become agitated and began yelling, cursing, and slamming doors while in the room with RI #114. RI #114 had diagnoses including muscle weakness and spina bifida. The facility investigative file stated the charge nurse reported RI #19 was agitated to the unit manager, but the Administrator was not aware of the incident until 08/25/2025, when the DON returned from vacation and asked about the resident threatening the roommate. The Administrator stated the incident should have been reported to her immediately.
Pain medication not provided as ordered for resident with severe pain
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident admitted with a right fibula fracture and right ankle discoloration after surgery. On admission, the resident was assessed with pain rated 7 out of 10, and the ordered oxycodone 5 mg was not yet available in the facility for administration. The resident’s pain medication was delivered later, but the resident was not medicated until the next morning, when the pain level had increased to 8-9 out of 10. The resident’s physician order specified oxycodone 5 mg, two tablets for moderate pain rated 4-7 and four tablets for severe pain rated 8-10. The medication administration record and controlled drug record showed the resident received only one tablet when the pain level was documented as 9, rather than the ordered four tablets for severe pain. The resident’s progress note documented complaint of pain at 8 and that the resident called an ambulance to be taken to the hospital because of pain. Interviews and statements in the investigative file confirmed that staff knew the resident was in pain and that the ordered pain medication was not available at the time it was needed. The former DON stated no pain medication was given at the time of admission, and an LPN stated she did not provide pain medication because the ordered medication was not in the stat box. The RN later stated she gave pain medication shortly before the resident left for the hospital, and the resident reported not receiving medications and calling 911 due to pain.
Delay in Faxing Medication Orders Left Pain Medication Unavailable
Penalty
Summary
The facility failed to ensure RI #120’s medication orders were faxed to the pharmacy in a timely manner so the resident’s ordered pain medication, Oxycodone 5 mg, was readily available for administration. RI #120 was admitted with diagnoses including an unspecified fracture of the shaft of the right fibula, subsequent encounter for closed fracture with routine healing, and discoloration of the right ankle joint, subsequent encounter. The deficiency was identified during investigation of a complaint/FRI alleging the resident did not receive medication for 38 hours. The facility’s investigative file showed that discharge paperwork for RI #120 was received and an admission alert was sent with the resident’s medications and scripts. However, the medical records nurse, who was responsible for faxing medication orders to the pharmacy, stated she received the email with the medication orders but did not fax RI #120’s orders because of a family emergency. She was not sure when the orders were ultimately faxed. The admissions coordinator stated the alert was sent, but medical records was responsible for sending the medication list to the pharmacy. During the resident’s stay, LPN #31 reported that RI #120 requested pain medication on the morning of 04/02/2026, but the medication was not in the stat box, so it was not given. The consultant pharmacist stated that if ordered pain medication was not available in the facility or stat box, the nurse should check with the pharmacy and obtain it from the backup pharmacy if needed, and that pain medication should always be available. The interim DON stated the resident should always have pain medication available, and the facility’s investigation identified an admission process failure resulting in a delay of a new admission receiving medications per MD orders.
Improper Handling of Clean Laundry
Penalty
Summary
The facility failed to implement and maintain an effective infection control program related to the handling of clean laundry. During observation, Laundry Staff #45 was folding clean flat sheets in the clean laundry area while multiple sheets touched the front of her clothing, and she was not wearing an apron. The facility policy titled "Laundry- Storage, Collection & Transportation" stated that all linens are to be stored, handled, transported, and processed in a manner that prevents the transmission of microorganisms to other patients and areas. When asked about the concern, the Environmental Service Director identified infection control as the issue, and the Clinical Care Coordinator/Interim DON also stated that clean linen touching the front of laundry staff's clothing while folding linen would be an infection control concern.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure nurse staffing was posted every day on the REPORTS OF NURSING STAFF DIRECTLY RESPONSIBLE FOR RESIDENT CARE form. Survey observations found that the night shift was not completed on 04/21/2026, 04/23/2026, 04/28/2026, 04/29/2026, 05/01/2026, 05/04/2026, 05/06/2026, and 05/19/2026, and the evening shift was also not completed on 05/19/2026. In each observed instance, the form was displayed in the front lobby in a clear acrylic stand-alone frame, but the missing entries left the number of staff and total hours worked incomplete. The postings also did not include the resident census. During interview on 05/20/2026, the Interim DON stated that the scheduler and a chosen night shift charge nurse were responsible for updating the form as needed, and said the form should include the facility name, date, total number and actual hours worked by RN, LPN, and CNA staff, and resident census. The IDON also stated the posting should be completed at the beginning of the shift and identified the specific shifts that were not filled out on the noted dates.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huntsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Ct Skilled Care Ctr At Magnolia Trace | 1.3 mi | ★★★★★ | 0 | 0 |
| Rocket City Rehabilitation And Healthcare Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Big Springs | 3 mi | ★★★★★ | 0 | 0 |
| Brookshire Healthcare Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Windsor House | 3.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.