Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Mitchell-hollingsworth Nursing & Rehabilitation during CMS and state inspections, most recent first.
Inadequate diagnosis for atypical antipsychotic use: A resident with dementia and other acute conditions was ordered quetiapine for unspecified dementia without behavioral disturbance, while a physician-signed document stated the medication was for dementia with behavioral disturbances. Facility policy required psychotropic use only with adequate indication, but consultant pharmacist MRRs did not identify the diagnosis discrepancy, and the DON stated the pharmacist was expected to catch it.
Failure to provide written transfer and bed hold notices for two residents. One resident was transferred after a fall with pain and EMS transport, and another resident had multiple hospital transfers for sepsis, feeding tube drainage, an unresponsive episode, and AMS. The EMR contained transfer notices, but there was no evidence they were mailed or otherwise provided in writing to the RR/FM. The QIRN stated the family was only called, and an RN said the family would only get paperwork if they came in to pick it up.
The facility failed to complete thorough RCA for two residents who fell and sustained fractures. One resident with dementia and severe cognitive impairment was found on the floor with a right trochanter fracture, and the RCA documented the injury and transfer to the ER but did not investigate how the fall occurred. Another resident with multiple mobility and neurologic diagnoses was found on the floor with hip and elbow pain and later a left hip fracture; the RCA repeated the event details but did not identify a cause or include witness statements, and the DON confirmed the cause was not determined.
Failure to Attempt Alternatives Before Using Bed Rails: The facility failed to ensure alternatives were tried before using side rails for two residents. One resident had severe cognitive impairment and diagnoses including pelvic fracture, dementia, and agitation, while the other was cognitively intact with diagnoses including critical illness myopathy and recurrent pneumonia. Bed side-rail safety assessments were largely blank for alternative approaches, and staff stated that alternatives were not really attempted in the past and that rails were provided when requested by residents or families.
A facility failed to ensure expired medications were not available for resident use when an opened PPD vial was found in the 200-hall med room refrigerator. An LPN verified the vial had exceeded the manufacturer’s 30-day discard timeframe, then returned it to the refrigerator, and the DON stated it should have been moved to discontinued meds and not left available for use.
Resident-to-resident physical abuse occurred when one severely cognitively impaired resident with wandering and physical behaviors hit another resident in the face in the hallway, causing the resident to stumble backward and report pain. The abused resident had dementia, severe cognitive impairment, and a care plan for wandering and intrusive behaviors, while the other resident also had severe cognitive impairment, hallucinations, delusions, wandering, and physical behaviors toward others. The facility’s investigation concluded the event was physical abuse witnessed by CNA staff.
Inadequate Diagnosis for Atypical Antipsychotic Use
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for unnecessary medications, Resident 7, had an appropriate diagnosis for the use of an atypical antipsychotic medication in the setting of dementia. The facility policy stated psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and only for the resident’s medical symptoms, and that adequate indication must be consistent with accepted standards of practice and evidence-based references. Another facility policy stated medication regimen review irregularities include use of medications without adequate indication and that the facility should provide timely responses to such irregularities. Resident 7 was admitted with diagnoses including pelvic fracture, dementia without behavioral disturbance, delirium, somnolence, lack of coordination, altered mental status, and restlessness and agitation. The EMR showed orders for quetiapine 100 mg at bedtime and quetiapine 25 mg daily related to unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician-signed document in the record stated the resident was prescribed Seroquel for dementia with behavioral disturbances, but the EMR diagnosis remained dementia without behavioral issues. Consultant pharmacist medication reviews completed in August and September 2025 did not identify any recommendations regarding the resident’s atypical antipsychotic use, and the DON stated the pharmacist was expected to identify the discrepancy.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that two of three residents reviewed, R3 and R12, or their resident representatives/family members received written notice of facility-initiated emergent transfers to the hospital and/or a written bed hold notice. The deficiency was identified during record review, interview, and facility policy review, and involved transfer notices that were present in the medical record but not shown to have been provided in writing to the resident representative or family member. Facility policy titled "Transfer and Discharge (including AMA)" stated that transfer/discharge notices are to be provided to the resident and representative in a language and manner they can understand and must include the reason for transfer, effective date, location, appeal rights, state appeal contact information, appeal form information, assistance information, Ombudsman contact information, and other required information. For R3, the EMR showed a fall with left hip and elbow pain, x-rays ordered, and transfer by EMS to the hospital. The transfer/discharge notice dated 07/19/25 indicated the resident was unable to sign, and the box indicating the form was mailed to the RR or FM was not checked. For R12, the EMR showed multiple hospital transfers for sepsis, purulent drainage around a feeding tube site, an unresponsive episode, and altered mental status with diaphoresis. Transfer notices were present for those events, but there was no evidence that the notices had been provided to the RR or FM. During interview, the QIRN stated nothing was provided in writing to the RR/FM and that the family was only called and aware of the transfer. FM12 stated she communicated with the facility by phone or in person, clarified that the transfers were emergent, and said nothing had been mailed or provided in writing. RN1 described the transfer process as calling the physician, calling 911, notifying the family, and preparing transfer paperwork and a bed hold agreement, but stated she was not aware of anything being provided to the family unless they came in to get it.
Incomplete fall root cause analyses for two residents with injuries
Penalty
Summary
The facility failed to conduct a thorough falls root cause analysis for two residents who experienced falls with injuries. The facility policy titled, Fall Prevention Program, stated that when any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, complete an incident report, notify the physician and family, review and update the care plan as indicated, document all assessments and actions, obtain witness statements in the case of injury, and initiate an intervention appropriate to the cause of the fall to reduce recurrence. One resident had diagnoses including Alzheimer's disease, dementia, and osteoarthritis, and was severely cognitively impaired with a BIMS score of 3 out of 15. The resident's care plan identified potential for falls related to dementia, poor safety awareness, psychotropic medication, wandering, pain, and anemia, and included multiple fall-related interventions. After the resident was found lying on the floor with a right trochanter fracture, the facility's RCA documented the injury, physician notification, family notification, transfer to the ER, and addition of a silent bed alarm, but it did not include any investigation into how the fall occurred. During interview, an LPN stated she was not present when the fall occurred and only found the resident on the floor after arriving to work. A second resident had diagnoses including intervertebral disc degeneration, back pain, tremors, fall history, weakness, history of poliomyelitis, generalized muscle weakness, difficulty walking, altered mental status, and restlessness and agitation. After the resident was found on the floor inside the room door with left hip and elbow pain and later transferred by EMS with a left hip fracture, the facility's RCA repeated the fall description and noted changes in care, including relocation of the resident and a bed alarm, but did not identify a cause of the fall or include witness statements. The DON reviewed the RCA and confirmed there was no cause identified and no witness statements included, and stated that knowing how a fall occurred is important to set an intervention to keep it from happening again.
Failure to Attempt Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to ensure alternatives were attempted before using side rails for two residents, R7 and R12, who were reviewed for side rail use. The facility policy titled, Proper Use of Bed Rails, stated that a person-centered approach should be used and that appropriate alternative approaches are to be attempted prior to installing or using bed rails. The policy also stated that resident assessment may include evaluation of alternatives attempted before bed rail use and how those alternatives failed to meet the resident’s assessed needs. R7 was admitted with diagnoses including pelvic fracture, dementia, delirium, somnolence, lack of coordination, altered mental status, and restlessness and agitation. The MDS showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. R7 was observed with bilateral upper bed rails in place on multiple occasions. The Bed Side-Rail Safety Assessment dated 08/05/25 had blank entries for the sections asking for side rail alternatives considered but not attempted and alternatives attempted that failed to meet the resident’s needs, while the form indicated that both the resident and family requested bedside rails. The care plan included bed rails for safety, mobility, and weakness. R12 was admitted with diagnoses including critical illness myopathy, recurrent pneumonia, type II diabetes, anxiety, venous embolisms, osteoarthritis, and fibromyalgia. The quarterly MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. R12 was observed in bed with bilateral upper bed rails, and later the rails remained up even when the resident was out of the room. Multiple Bed Side-Rail Safety Assessments were reviewed, and the sections for alternatives considered but not attempted and alternatives attempted that failed to meet the resident’s needs were blank on each assessment except one marked N/A. The care plan included left and right 1/4 length side rails for bed mobility and transfers, with additional interventions noting comfort, security, and use as a hand-hold for getting in and out of bed and during transfers. During interview, the QIRN stated the facility reviewed risk and benefits with the family and that if side rails were requested, they were provided; the DON stated the facility really never had attempted alternatives in the past.
Expired PPD Vial Left Available in Medication Room Refrigerator
Penalty
Summary
The facility failed to ensure expired medications were not available for resident use in the 200-hall medication room refrigerator. During observation of the medication room with an LPN, a tuberculin purified protein derivative (PPD) vial was found in the refrigerator with an opened date of 07/29/25 on the box. The LPN verified the open date and reviewed the product labeling, which stated that after the vial had been entered it should be discarded after 30 days. After confirming the vial was expired, the LPN placed it back in the refrigerator and stated she would dispose of it later. During interview, the DON stated the PPD should have been moved to discontinued medications and, if not moved, it may have been stored in the refrigerator but should not have been available for resident use. The issue was identified in one of three medication rooms reviewed and had the potential to affect the 37 people residing on the 200 hall.
Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that one of 38 sampled residents, R137, was free from abuse. R137’s record showed a history of Alzheimer’s disease, dementia, major depressive disorder, psychotic disorder with delusions due to a known physiological condition, and type 2 diabetes. The annual MDS indicated a BIMS score of 3 out of 15, showing severe cognitive impairment, and the care plan documented wandering into other residents’ rooms, exit seeking, disrobing, voiding in inappropriate places, and pushing other residents in their chairs. R220’s record showed diagnoses including senile degeneration of the brain, neurocognitive disorders with Lewy bodies, dementia with mood disorder, agitation, anxiety, and psychotic disorder with delusions. The quarterly MDS also showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and documented hallucinations, delusions, wandering, rejection of care, physical behaviors toward others, and verbal behaviors. The care plan identified behaviors including wandering into others’ rooms, exit seeking, and physical behaviors directed toward others. The facility’s abuse investigation report stated that R220 and R137 were standing in the hallway when CNA 5 heard R137 raise [his/her] voice and then witnessed R220 hit R137 in the face, causing R137 to stumble backward into a resident’s room without falling. CNA 5 assisted R137, who said, “oh it hurts,” and a red area above the lip was noted. The report concluded that the event was a resident-to-resident altercation of physical abuse. The DON stated during interview that he recalled the incident and that it was witnessed by the CNA.
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Reposo Nursing Facility | 0.9 mi | ★★★★★ | 0 | 0 |
| Florence Nursing And Rehabilitation Ctr, Llc | 2.9 mi | ★★★★★ | 0 | 0 |
| Glenwood Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Keller Landing | 4.7 mi | ★★★★★ | 0 | 0 |
| Cypress Cove Care Center | 5.3 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.