Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Haven Health And Rehabilitation Center during CMS and state inspections, most recent first.
Resident-to-resident physical abuse occurred when one resident, after complaining that another resident entered his/her room, shoved the wandering resident out into the hallway. The injured resident fell face down and sustained a laceration above the eye, bleeding, bruising, pain, and CT/X-ray-confirmed facial fractures. Witnesses, the ADON, CNAs, LPN, and the facility’s investigation all described the event as physical abuse.
Menu portion sizes were not followed for chopped and puree diet items when staff used a 3 oz spoodle, a #8 dipper, and a #12 dipper instead of the #10 and #6 dippers listed on the preplanned menu. An employee and the Dietary Supervisor both confirmed the utensils used did not match the menu, and the Dietary Supervisor said the shortage of serving dippers/scoops contributed to the issue and that residents could potentially be affected by weight loss.
Frozen Food Storage and Temperature Control Failure: The facility failed to keep food frozen solid in a reach-in bread freezer and failed to maintain proper cold holding temperatures. During a kitchen tour, items such as pancakes, French fries, onion rings, and hush puppies were soft to touch, and the freezer’s internal thermometer read 45 degrees F. A service invoice noted the condenser coils were completely clogged with dirt, and the Maintenance Director said the freezer went down because the A/C was broken and hot, humid air from the kitchen contributed to the coils clogging.
No Refrigerated Storage for Outside Food: The facility failed to provide a refrigerator area for food brought in by family or visitors, despite a policy allowing such items to be stored in the food service dept. The Dietary Supervisor said staff stopped the food at the door and had no room for resident food, and Resident Council members reported there was no place to store it, so it had to be thrown away or eaten the same day.
Improper Dumpster and Grease Refuse Area Sanitation: Surveyors observed trash debris around dumpsters, a heavy greasy buildup on the oil/grease refuse container, and a large fly concentration near the refuse area. Staff said Maintenance and Housekeeping shared responsibility for keeping the area clean, but the area was not maintained free of litter and attractants. Flies were also observed in the kitchen and a resident reported flies in his room, while residents in Council reported flies landing on food and disturbing sleep.
Inaccurate PBJ Staffing Data Submission: The facility failed to submit complete and accurate direct care staffing data to CMS for a quarter of PBJ reporting. The PBJ report showed an excessively low weekend staffing trigger, and the ADM stated she compiled the data, sent it to corporate, and a third-party company submitted it to CMS, while also acknowledging she did not know why the low weekend staffing was triggered.
The facility failed to keep several resident bathrooms in good repair and sanitary condition. Surveyors observed broken tiles and holes behind commodes, water-damaged walls, and dirty floors with urine in multiple bathrooms. The HSUP said the bathrooms were cleaned daily, but urine on the floor contributed to the condition and a floor replacement would be needed. Surveyors also observed brown spots in hallways and a fly near breakfast trays being removed from resident rooms.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
A resident with Type 2 DM had a physician order for BG checks before meals and at bedtime, with provider notification for readings above 250 mg/dL. The MAR showed multiple BG results above that threshold, but there was no documentation that the MD or other provider was notified. RN confirmed the order, the MD had no recollection or record of notification, and the DON stated there was no evidence the notifications occurred.
PASRR Level II Evaluation Not Completed Timely: A resident with PTSD and GAD had a PASRR Level I screening that identified the need for a Level II eval, but the required review was not completed when the resident was admitted. The SSD acknowledged the PASRR process was not completed as required and stated the omission was later identified during a chart update.
Failure to develop timely oxygen care plans for two residents. One resident with pneumonia and another with HF had physician orders for O2 at 2L via NC PRN for SOB, and observations showed both residents receiving O2 in bed. Care plan review showed no documented oxygen care plan until later, and the MDS Coordinator stated residents on oxygen should have a care plan so staff know the resident requires oxygen use and the reason for it.
Failure to investigate multiple skin tears for a resident with dementia, hemiplegia/hemiparesis, and a hx of falls. Facility records showed treatment orders and notes that the sponsor was notified of new skin tears, but there was no evidence identifying how the injuries occurred. The facility policy classified skin tears as incidents requiring an incident/accident report, investigation, and witness statements, yet the TX nurse and ADM could not confirm an investigation had been completed, and the event summary report showed none.
A resident with aspiration risk and orders for nectar-thick liquids had a water pitcher with thin liquids observed at the bedside on multiple occasions. The resident’s care plan directed staff not to keep a water pitcher in the room and to provide thickened liquids, but the pitcher was later found on the over-bed table with no thickener in it. Staff interviews confirmed the resident was supposed to receive nectar-thick fluids, and nursing was responsible for ensuring the correct consistency.
Undated Oxygen Humidifier Bottles: Two residents receiving O2 via NC had humidified water bottles that were not dated during survey observations. An LPN, the IP, and the RN UMGR confirmed the bottles lacked dates, and staff stated the bottles should be dated and changed weekly. One resident had pneumonia and an order for O2 PRN for SOB; the other had HF and an O2 order PRN for SOB.
Failure to Address Wandering Resident Entering Another Resident’s Room: A resident with dementia and a known wandering pattern repeatedly entered another resident’s room after staff were told the other resident did not want him/her there. No additional behavior interventions were put in place at that time, and the wandering resident later entered the room again, was pushed out by the other resident, and sustained a facial fracture.
Failure to document narcotic medication administration on the MAR. A resident with diagnoses including a left artificial hip joint, polyneuropathy, and cellulitis had orders for Norco and Lyrica, but the MAR had no initials showing the doses were given on two occasions. An RN said she probably forgot to sign after administering the meds, another RN said she overlooked signing, and the RN UM confirmed the MAR was not signed as required by policy.
Therapeutic Diet Not Served as Ordered: A resident with ESRD on dialysis and muscle weakness had a physician order for large portions, boiled eggs at breakfast, and double meat for protein. Meal observations showed the resident received only one boiled egg and one sausage patty at breakfast and two chicken wings at lunch, which the DS and RD confirmed were not the ordered double portions.
A facility arbitration agreement stated that a resident was not required to sign to be admitted or continue care, but it required rescission within 30 days by signed written letter only. The SSD said she explained the agreement before admission and confirmed that verbal withdrawal was not allowed, meaning residents or representatives could only retract consent in writing.
An unqualified Dietary Supervisor directed the facility’s Food Service/Dietary Department without meeting the minimum qualifications for a CDM or director of food and nutrition services. Although she completed a UF nutrition and foodservice training pathway, she told surveyors she had not taken or scheduled the CDM exam and had no degree in Nutrition, Hospitality, or Food Service. The deficiency affected 84 of 84 residents receiving meals from the department.
A facility failed to keep dinner-to-breakfast meal service within the 14-hour limit required by its policy for Rehab/West Hall, North Hall, South Hall, and Meal Assist. The Resident Council said they had not agreed to a longer span, and the Dietary Supervisor confirmed that some carts exceeded 14 hours between dinner and breakfast, noting residents who request snacks and diabetic residents receive HS snacks and that the issue could affect weight loss.
Residents did not receive mail on weekends because mail delivered by USPS on Saturday was held until Monday. During a resident council meeting, residents said there was no one to pass out the mail. The SSD was unsure of the process, the Bookkeeper said mail was stored in a locked room and given to the ADM on Monday, and the ADM stated resident mail should be given out when received but there was no policy directing staff on Saturday mail handling.
A resident with epilepsy, cognitive communication deficit, HTN, and CKD was transferred to the hospital twice after acute changes in condition, including disorientation, agitation, breathing difficulty, and a seizure. The facility gave verbal notice to the family, but the SSD, ADM, and the resident’s representative confirmed no written transfer notice was provided for either transfer, despite the discharges being marked with return anticipated.
Resident-to-Resident Physical Abuse After Room Intrusion
Penalty
Summary
The facility failed to ensure one resident was free from resident-to-resident physical abuse when another resident pushed him/her out of a room and into the hallway, causing a fall and injuries. The injured resident had diagnoses including unspecified dementia, mood disorder, anxiety, cognitive deficit, and adjustment disorder, and had a BIMS score of 11/15 with documented long- and short-term memory problems. The resident was also identified in the care plan as wandering into other residents’ rooms. The other resident involved had diagnoses including dementia with agitation, psychotic behaviors, mood disturbance, anxiety disorder, and memory impairment, and had a BIMS score of 15/15. On the day before the incident, the resident told the SSD and ADON that another resident had entered his/her room and that he/she wanted that resident to leave him/her alone. The SSD and ADON told the resident they would discuss it with the other resident and let him/her know not to come into the room, and the resident stated he/she understood. The next day, the resident who had complained pushed the wandering resident out of the room after the wandering resident entered the room without permission. Witness statements and staff interviews described the wandering resident being shoved into the hallway, falling face down, and sustaining a laceration above the left eye, bleeding, bruising, and pain. Hospital imaging documented mildly displaced fractures of the left maxillary sinus wall and lateral border of the left orbit, and the facility’s investigation substantiated resident-to-resident physical abuse.
Menu Portion Sizes Not Followed for Texture-Modified Diets
Penalty
Summary
The facility failed to follow the planned menu and the posted scoop and dipper sizes for texture-modified diets. The Spring/Summer 2026 menu specified that chopped Hamburger Steak for lunch on Tuesday, 06/23/2026, was to be served with a #10 dipper, and Puree Lasagna for dinner that same day was to be served with a #6 dipper. On Wednesday, 06/24/2026, the menu specified that chopped Fried Chicken and Puree Fried Chicken for lunch were each to be served with a #10 dipper. The facility’s diet manual and menu policy stated that menus are to be preplanned, followed, and include the correct portion size for each modified diet item. During observations, a 3 oz. spoodle was used for chopped Hamburger Steak at lunch, a #8 dipper was used for Puree Lasagna at dinner, and a 3 oz. spoodle was used for chopped Fried Chicken while a #12 dipper was used for Puree Fried Chicken at lunch. The Dietary Supervisor and an employee both stated the menu was not followed and acknowledged that the utensils used were not equal to the portion sizes listed on the menu. The Dietary Supervisor also stated there was a shortage of serving dippers/scoops because some had broken, and that the residents could potentially be affected by weight loss from the menu not being followed.
Frozen Food Storage and Temperature Control Failure
Penalty
Summary
The facility failed to ensure food was frozen solid in the Two-door Reach-in Bread Freezer and failed to maintain the internal temperature at or below 41 degrees F. During the initial kitchen tour on 06/22/2026 at 4:04 PM, the freezer contained pancakes, French fries, onion rings, and hush puppies that were soft to touch, and the internal thermometer read 45 degrees F while the external digital thermometer read 31 degrees F. The report states this affected 84 of 84 residents receiving meals from the Food Service Department. A service invoice dated 06/22/2026 documented that the freezer had reached 45 degrees and was brought down to 0 degrees after the condenser coils were found completely clogged with dirt. The invoice also stated the maintenance man needed to clean the coils monthly. On 06/25/2026, the Maintenance Director said filters and coils were cleaned every 30 days or as needed, that he drained the condenser line and checked defrosting, and that the freezer went down because the A/C was broken and the blowers pushed hot air and humidity from the kitchen through the condenser coils. He also said the A/C had been out for 10 days and that the coils had been cleaned two to three weeks earlier. The Maintenance Director did not provide the requested maintenance records.
No Refrigerated Storage for Food Brought in by Family or Visitors
Penalty
Summary
The facility failed to ensure there was a refrigerated area for storing food brought in for residents by family and friends, despite having a policy titled FOOD FROM OUTSIDE SOURCES that stated food brought to residents by family, visitors, or volunteers is to be handled in a safe and sanitary manner and may be stored in the food service department in a refrigerator or freezer immediately. The policy also stated refrigerated cooked food not prepared in the facility is to be held no longer than 24 hours and labeled with the resident’s name, room number, date received, and discard date. On 06/23/2026, the Dietary Supervisor stated the facility did not keep items brought in by friends and family for individual residents, that dietary staff stopped the food at the door, and that dietary did not have room for resident food. At Resident Council on 06/24/2026, 11 of 11 members said there was no refrigerator available for residents’ food when family brought items in, and that the food had to be thrown away or eaten the same day. The council members also said dietary staff told them there was no place to put the food, and all 11 said residents wanted a refrigerator to store their food.
Improper Dumpster and Grease Refuse Area Sanitation
Penalty
Summary
The facility failed to keep the Dumpster/Oil & Grease Refuse Area clean and free of debris. On 6/22/2026, surveyors observed small particles of trash around the two dumpsters, including a balled-up piece of aluminum foil, a piece of a clothes hanger, and a small bottle with an eye-dropper. In the same area, there was a concentration of about 30 to 40 flies in a small grassy section within the pavement near the dumpsters. The Dietary Supervisor stated Maintenance was responsible for maintaining the area and said Maintenance rinsed the dumpster area daily. Surveyors also observed a build-up of greasy particles on the outside of the oil/grease refuse container. The build-up was around the top opening of the container and extended to the top of the opening's cover, measuring approximately two inches. The Dietary Supervisor stated the build-up should be washed down when the dumpsters were washed down, which should be daily or as needed, and said it did not appear the oil/grease refuse container had been washed daily when observed. The facility's pest control records showed fly treatment was last documented on 02/18/2026, despite later records dated 04/29/2026 and 06/08/2026. During the survey, a fly was observed in the kitchen on the plate lowerator, and later flies were observed flying in the kitchen during meal preparation and trayline activity. RI #8 complained of flies in his room, and during Resident Council, residents reported flies landing on food and waking them while sleeping. Staff interviews confirmed flies were present near the dumpsters and that the area could allow flies to enter the building.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for the quarter of 01/01/2026 through 03/31/2026. The PBJ report for that quarter documented a staffing data concern for excessively low weekend staffing, and the report stated that this metric was triggered because the submitted weekend staffing data was excessively low. During an interview on 06/25/2026, the Administrator stated she was responsible for submitting staffing data to CMS, did not know why the low weekend staffing was triggered for the second quarter of 2026, and explained that she compiled the data, sent it to corporate, and a third-party company submitted it to CMS. She also stated that if incorrect data was submitted, CMS would not have accurate information concerning staffing.
Unclean and Poorly Maintained Resident Bathrooms
Penalty
Summary
The facility failed to maintain resident care areas in good repair and in a sanitary condition. Surveyors observed broken tiles and holes behind the commode in the bathrooms belonging to RI #34, RI #26, RI #72, and RI #1. Surveyors also observed water-damaged walls in the bathroom belonging to RI #8, and dirty floors with urine observed on the floor in the bathrooms belonging to RI #8, RI #57, RI #5, and RI #36. The report states these conditions affected RI #34, RI #26, RI #72, RI #1, RI #8, RI #57, RI #5, and RI #36. The facility policies titled TELS Maintenance Services Work Order and Standard Method of Cleaning Checklist were cited in the report. The maintenance policy stated that when a need for maintenance services is detected, staff are responsible for reporting it by completing an electronic work order. The cleaning checklist directed staff to clean bathrooms and inspect rooms, reporting needed repairs and correcting deficiencies. During observation and interview, the Housekeeping Supervisor stated the bathrooms were cleaned daily during the daytime shift, but said urine on the floor contributed to the condition of the bathrooms and that the fix would be a floor replacement. The surveyor also observed brown spots on the main hallway and west unit floor, and a fly near breakfast trays being removed from resident rooms.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Failure to Notify Provider of Repeated Elevated Blood Glucose Readings
Penalty
Summary
The facility failed to follow a physician’s order requiring staff to notify the medical provider when RI #89’s blood glucose was below 70 mg/dL or above 250 mg/dL. RI #89 was admitted with a diagnosis of Type 2 Diabetes Mellitus without Complications, and the March 2025 order directed blood glucose checks four times daily before meals and at bedtime, with documentation of results and provider notification for readings outside the ordered parameters. Review of the Nurse Medication Administration History showed multiple blood glucose readings above 250 mg/dL, including values of 269, 309, 290, 316, 295, 278, 301, 279, 352, 300, 260, 281, 298, 259, 381, 301, and 261 mg/dL. The record contained no evidence that the physician or other provider was notified of these elevated readings. RN #11 confirmed the order required notification and stated no notification had been documented and no new orders were received. The MD stated he had no recollection or documentation of being notified, and the DON stated there was no evidence to validate physician notification in the absence of documentation in the medical record.
PASRR Level II Evaluation Not Completed Timely
Penalty
Summary
The facility failed to ensure compliance with PASRR requirements for RI #5 by not completing the required PASRR Level II Evaluation after the Level I screening identified the need for it. RI #5 was admitted with diagnoses of PTSD and Generalized Anxiety Disorder. The PASRR Level I Determination dated 11/07/2024 documented that, after QA review, the resident required a Level II Evaluation because of serious mental illness diagnoses, including PTSD and Generalized Anxiety Disorder, and also stated the resident met criteria for a categorical determination for convalescent care and could be admitted while the Level II Evaluation was completed. The Level I Determination further stated that the admitting nursing facility was required to report the admission to the OBRA PASRR Office at the time of admission to begin the Level II process and determine eligibility for specialized services. During interview, the SSD stated the Level I screening had been completed prior to admission, but the required Level II evaluation had not been completed at that time. She stated she did not recall whether the resident had been admitted under emergency admission or exempted hospital discharge, acknowledged responsibility for ensuring the PASRR process was completed, and stated the omission was identified during a chart update when the Level I PASRR screening was redone. She stated the Level II PASRR evaluation was completed later.
Failure to Develop Timely Oxygen Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan to address oxygen use for two residents. The facility policy titled, Care Plans, stated that plans of care are developed by the interdisciplinary team and that the comprehensive plan of care must include measurable objectives and timetables to meet a resident’s medical, nursing, and mental/psychological needs identified in the comprehensive assessment. The policy also stated that the comprehensive plan of care should be developed within 7 days of the full assessments. One resident was admitted and later readmitted with a diagnosis of pneumonia, unspecified organism, and had a physician order in June 2026 to administer oxygen at 2 liters via nasal cannula as needed for shortness of breath. Observations on 06/23/2026 and 06/24/2026 showed the resident lying in bed with oxygen on at 2L via nasal cannula, but the care plan review showed no documentation of a care plan for oxygen use until 06/24/2026. A second resident was admitted and later readmitted with a diagnosis of heart failure, unspecified, and had a June 2026 physician order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. An observation on 06/25/2026 showed the resident sitting up in bed with oxygen infusing at 2L via nasal cannula, and the care plan review showed no documentation of a care plan for oxygen use until 06/25/2026. The MDS Coordinator stated that residents who received oxygen should have a care plan for oxygen therapy and confirmed that neither resident had a care plan for oxygen use prior to those dates.
Failure to Investigate Resident Skin Tears
Penalty
Summary
The facility failed to provide evidence of how Resident Identifier #91 acquired multiple skin tears to the right upper shin, left knee, right buttocks, right hip, right knee, and right lower shin. The resident was admitted with diagnoses including senile degenerative disease of the brain, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and a history of falling. The physician orders included treatment orders for the skin tears, and progress notes documented that the sponsor was made aware of new areas found on the resident, but the documentation did not identify who first observed the injuries or how they occurred. The facility policy titled Incidents and Accidents stated that skin tears are incident types and that an incident/accident report should be completed, an investigation initiated, and witness statements obtained from employees with knowledge of or who witnessed the incident. During interview, the treatment nurse stated she did not recall whether an incident report had been completed and said the incident report would show how the skin tear occurred. The administrator stated she was not sure whether the skin tears had ever been investigated and acknowledged that skin tears were considered incidents under the facility policy. Review of the facility’s event summary report showed no incident report or investigation had been completed related to the resident’s skin tears.
Incorrect Liquid Consistency at Bedside
Penalty
Summary
The facility failed to ensure that a resident at risk for aspiration received nectar-thick liquids as ordered and planned for in the resident’s care plan. The resident had diagnoses including Alzheimer’s disease with late onset, esophageal obstruction, senile degeneration of the brain, and gastro-esophageal reflux without esophagitis. The care plan directed staff not to keep a water pitcher in the resident’s room and to provide thickened liquids, with a cooler containing thickened liquids at the bedside. The resident’s communication form, physician orders, and resident profile all reflected nectar-thick liquids, and the resident’s quarterly MDS indicated severely impaired cognition and a mechanically altered diet with thickened liquids. During survey observations, a water pitcher was seen at the resident’s bedside on multiple occasions, and later on the over-bed table in the resident’s room. When the pitcher was checked, it contained no thickener. A CNA stated the resident was on a pureed diet with thickened liquids but was unsure who was responsible for ensuring thickened water was at the bedside. The RD stated water should also be nectar thick for a resident with swallowing problems and that nursing staff were responsible for ensuring the correct consistency. The RN unit manager also stated the resident’s fluids should be nectar thick and that the water should be nectar-thick liquid as well.
Undated Oxygen Humidifier Bottles
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to ensure humidified oxygen water bottles were dated for two residents receiving oxygen therapy. RI #1, who was admitted and readmitted with a diagnosis including pneumonia, had a physician order for oxygen at 2 liters via nasal cannula as needed for shortness of breath. On 06/24/2026, RI #1 was observed lying in bed with oxygen at 2L via nasal cannula, and the humidified water bottle was not dated. During interviews, an LPN, the Infection Preventionist, and the RN Unit Manager each confirmed the bottle had no date and stated it should have been dated; the RN Unit Manager stated the date changed and nurse initials should be on the bottle. RI #35, who was admitted and readmitted with a diagnosis of heart failure, also had an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. On 06/23/2026 and again on 06/24/2026, observations showed RI #35's humidified water bottle was not dated. An LPN stated the bottle did not have a date but should have one. The MDS Coordinator stated oxygen tubing and humidified water bottles should be changed weekly and that the nurse on the unit was responsible for changing them, but she was not sure how the facility ensured they were changed.
Failure to Address Wandering Resident Entering Another Resident’s Room
Penalty
Summary
The facility failed to timely assess a behavior change and timely implement additional behavior interventions for a resident with a history of wandering. The resident had diagnoses of unspecified dementia, mood disorder, and adjustment disorder with mixed anxiety, and the annual MDS showed moderately impaired cognitive skills with long- and short-term memory problems. The resident’s care plan identified wandering into other residents’ rooms and noted the resident was at risk for elopement, with interventions including checking code alert placement each shift and consulting with the MD and psychologist as needed. On 04/15/2025, another resident with dementia and mood disturbance told the SSD and ADON that the wandering resident had come into his/her room and that he/she did not want the resident in the room. The SSD documented that the resident wanted to be left alone and that staff said they would discuss it with the other resident and tell him/her not to come into the room. The record did not show that interventions were added that day to prevent the wandering resident from entering the other resident’s room. On 04/16/2025, the wandering resident entered the other resident’s room again, and the other resident pushed the wandering resident out of the room, causing a fall and a fracture to the left maxillary sinus wall and lateral border of the left orbit. Interviews with staff showed the wandering resident had been observed going into the other resident’s room multiple times, staff had been notified, and the DON stated the resident was on general supervision with a code alert monitor. The DON also stated the incident could have been prevented by moving the wandering resident, and the facility substantiated abuse.
Failure to Document Narcotic Medication Administration on MAR
Penalty
Summary
The facility failed to ensure that medication nurses initialed the MAR after administering Hydrocodone-Acetaminophen (Norco) 10/325 mg and Pregabalin (Lyrica) 200 mg to RI #54. Review of the facility policy titled, Oral Medication Administration, showed that after administering medication, the nurse was to return to the medication cart and document the medication administration with initials in the appropriate space on the MAR. RI #54 was admitted with diagnoses including Presence of Left Artificial Hip Joint, Polyneuropathy, and Cellulitis, and had physician orders for Pregabalin 200 mg by mouth three times daily and Hydrocodone-Acetaminophen 10-325 mg by mouth twice daily for pain. Review of RI #54's May 2026 MAR showed no initials documenting administration of both medications at 6:00 AM on 05/02/2026 and at 6:00 PM on 05/25/2026. During interviews, RN #23 stated she probably forgot to sign the MAR after giving the medications on 05/02/2026, and RN #24 stated she must have overlooked signing the MAR after giving the medications on 05/25/2026. The RN Unit Manager confirmed the MAR was not signed for those doses and stated the facility policy required nurses to initial and sign the MAR after medications were administered.
Therapeutic Diet Not Served as Ordered
Penalty
Summary
The facility failed to ensure that Resident Identifier (RI) #3 received double portions of protein as ordered for a therapeutic diet. RI #3 was admitted with diagnoses of End Stage Renal Disease, dependence on renal dialysis, and muscle weakness. The resident’s admission MDS, with an ARD of 05/25/2026, indicated cognitive intactness and coded the resident as receiving a therapeutic diet. A physician’s order dated 05/26/2026 directed large portions to each meal tray, including boiled eggs on the breakfast tray and double meat on each tray for protein. During meal observations on 06/24/2026, RI #3’s breakfast tray contained one boiled egg and one thin turkey sausage patty, and the resident stated that his/her protein was low and the doctor had ordered more protein a few days earlier. At lunch, the tray contained two chicken wings. The Dietary Supervisor stated RI #3 should have received two boiled eggs and two servings of meat at breakfast, and that the two wings were only one serving, not a double portion, describing the issue as a kitchen mistake. The Registered Dietician later stated that four wings should have been served and confirmed that dietary staff were responsible for ensuring residents received double portions as ordered.
Arbitration Agreement Did Not Allow Verbal Rescission
Penalty
Summary
The facility failed to ensure arbitration agreements were implemented in a manner that protected resident rights. An agreement titled ARBITRATION AGREEMENT AND WAIVER OF JURY TRIAL stated that residents were not required to sign the agreement to be admitted or continue receiving care, but it also required any rescission to be made by sending a signed written letter to the facility within the first 30 days after signing. During interview, the Social Service Director stated that her role was to explain the arbitration agreement to residents and families before admission, and that after signing, a resident or representative had 30 days to retract consent only by submitting a written request. She confirmed that the agreement did not allow verbal withdrawal from the agreement.
Unqualified Dietary Supervisor Directed Food Service Department
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian. Survey findings showed that the Dietary Supervisor in charge of the Food Service/Dietary Department did not meet the minimum qualifications to serve as the director of food and nutrition services. The facility’s Certified Dietary Manager job description required the person in that role to be a Certified Dietary Manager in good standing with the State of Alabama or to be in training to satisfactorily complete the requirements to become a Certified Dietary Manager. The Dietary Supervisor had a certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida, but she told surveyors that she had not taken the CDM test yet, had not scheduled it, and had no Associate’s or Bachelor’s degree in Nutrition, Hospitality, or Food Service. She also stated that she had completed the CDM course in September 2025 and had worked in the position for eight years managing the Food Service Department. The Administrator acknowledged that the Dietary Supervisor had been in training but had not completed it, and said she had followed up and encouraged completion of the training. The report states that this affected 84 of 84 residents receiving meals from the facility’s Food Service/Dietary Department while it was under the direction of an unqualified individual.
Meal service times exceeded the 14-hour limit between dinner and breakfast
Penalty
Summary
The facility failed to ensure meal cart deliveries were scheduled so that no more than 14 hours elapsed between dinner and breakfast for residents on Rehab/West Hall, North Hall, South Hall, and Meal Assist. The facility’s policy for Frequency of Meals stated there should be no more than a 14-hour span between a substantial evening meal and breakfast, and the facility’s meal service times showed dinner carts beginning at 5:00 PM and breakfast carts beginning at 7:15 AM, 7:30 AM, 7:40 AM, and 8:00 AM for the respective halls and meal assist area. During the Resident Council meeting, eleven residents stated they had not agreed to a time span greater than 14 hours between dinner and breakfast. The Dietary Supervisor was interviewed and acknowledged that residents requesting snacks and diabetic residents receive an HS snack, and that 14 hours was allowed between dinner and breakfast. While reviewing the meal service times, the Dietary Supervisor stated there were 14 hours and 15 minutes between dinner and breakfast for Rehab/West Hall, North Hall, and Meal Assist, and 14 hours and 10 minutes for South Hall. When asked how the time periods extending over 14 hours could affect residents, the Dietary Supervisor said weight loss.
Delayed Weekend Mail Delivery
Penalty
Summary
Residents did not receive mail in a timely manner because mail received on Saturdays was not delivered to them. The facility's Resident Rights, revised 01/2017, stated that residents have the right to access private communication of all kinds. During a Resident Council Meeting on 06/23/2026, eleven residents stated that they did not receive mail on the weekend, and when asked why, they said there was no one to pass the mail out. On 06/25/2026, the Social Services Director stated she was not sure how Saturday mail was handled and said no one worked in the business office on Saturdays. The Bookkeeper stated the postman brought mail to the main station, staff stored it in a locked room, and it was given to the Administrator on Monday morning before being delivered to residents. The Administrator stated USPS did deliver mail on Saturday, that resident mail should be given to residents when received, and that there was no policy directing staff on what to do with resident mail received on Saturday.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide Resident Identifier #80 and the resident’s representative with a written notice of transfer when the resident was transferred to the hospital on [DATE] and again on 03/16/2026. RI #80 was admitted to the facility with diagnoses including epilepsy, cognitive communication deficit, hypertension, and chronic kidney disease. Progress notes showed that on 03/08/2026 around 9:45 AM, RI #80 was yelling in the room, was very disoriented and agitated, had difficulty breathing, and was transported to the hospital. The discharge summary assessment for that transfer indicated the discharge was with a return anticipated, and RI #80 was readmitted on 03/13/2026. A second transfer occurred on 03/16/2026 when RI #80 had a seizure at 4:47 AM and left the facility on a stretcher by ambulance. The discharge summary assessment again indicated a discharge with a return anticipated, and RI #80 was readmitted on 03/20/2026. Interviews with the Social Services Director and Administrator confirmed the facility did not provide written transfer notices for either hospital transfer, and the Administrator stated nurses gave verbal notification to family members but no written notification was provided. RI #80’s representative also stated she was called by telephone about both transfers but did not receive a written notice explaining the reason for transfer, the destination, or the date of transfer.
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Nursing homes near Tuskegee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tallassee Health And Rehabilitation, Llc | 17.2 mi | ★★★★★ | 0 | 0 |
| Arbor Lake Health And Rehab | 19.9 mi | ★★★★★ | 0 | 0 |
| Southern Springs Healthcare Facility | 20.2 mi | ★★★★★ | 0 | 0 |
| Arbor Springs Health And Rehab Center, Ltd | 22.2 mi | ★★★★★ | 0 | 0 |
| Dadeville Healthcare Center | 27.9 mi | ★★★★★ | 0 | 0 |
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