Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Mobile Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of falls, cognitive impairment, and significant physical limitations was transferred by a CNA without the required two-person assistance or use of a mechanical lift, contrary to the resident's care plan. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the CNA acted alone and did not follow established protocols.
The facility did not provide a private area for Resident Council meetings, instead holding them in the dining room where staff frequently entered and were within hearing distance of residents' discussions. Several residents, including those with intact and moderate cognition, reported that staff continued to enter the meeting space despite signage, and the facility's policy requiring privacy for these meetings was not followed.
A resident with a history of Bipolar disorder and depression was prescribed multiple psychotropic medications, but staff did not monitor or document the side effects or efficacy of these medications as required by facility policy. Interviews with the DON, a unit manager, and an LPN confirmed the absence of monitoring orders and documentation until nearly a month after the medications were started.
Two residents did not have comprehensive care plans addressing their specific needs: one with end stage renal disease receiving hemodialysis lacked a dialysis care plan, and another with chronic pain and moderate cognitive impairment did not have a pain management care plan, despite having active orders for pain medications. Facility staff acknowledged these omissions and confirmed that care plans should have been in place.
A resident with a history of venous insufficiency and thrombocytopenia was prescribed apixaban, but staff did not monitor or document side effects or efficacy of the anticoagulant until an order was added nearly a month later. Interviews with the DON, a unit manager, and an LPN confirmed that monitoring should have occurred and been documented, but was not done during this period.
A resident with severe cognitive impairment and a history of falls was repeatedly found with their call light out of reach, despite care plan interventions and facility policy requiring accessibility. Staff and leadership confirmed the expectation that call lights be within reach, but observations and interviews revealed the call light was often wrapped around the bed enabler, making it inaccessible to the resident.
A resident with a history of dysarthria alleged that an RN pushed and cursed at them during care. The RN did not report the abuse allegation as required by facility policy, and the incident only came to light when the resident's family member informed staff. This resulted in a delay in notifying the state survey agency within the mandated timeframe.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with intact cognition and heart failure, as required by policy. Although a male CNA was identified as working during the relevant shifts, there was no evidence he or other male staff were interviewed, and the investigation lacked documentation of attempts to contact them.
A resident with an anxiety disorder did not receive prescribed alprazolam at bedtime on several occasions because the medication order was never sent to the pharmacy. Nursing staff documented the medication as unavailable and did not escalate the issue, while the pharmacy confirmed no order was received. The DON later verified the order was not faxed, resulting in the resident not receiving the medication as prescribed.
A resident with multiple comorbidities developed a perineal rash that was observed and reported by a CNA to two different LPNs on separate occasions. Both LPNs provided cream but did not document the skin issue or notify a physician, and no record of the rash was found in the medical chart. The DON and Executive Director confirmed that documentation and assessment were expected but not completed.
Failure to Follow Transfer Protocols Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and daily care guide during a transfer, resulting in a fall and injury. The resident, who had a history of falls, cerebral palsy, autistic disorder, osteoporosis, morbid obesity, and moderate cognitive impairment, was care planned for two-person assistance with a mechanical lift for all transfers. Despite these documented requirements, a certified nursing assistant (CNA) attempted to transfer the resident alone and without the mechanical lift, after the resident expressed reluctance to use the lift. During the transfer from wheelchair to bed, the CNA held onto the back of the resident's pants as the resident attempted to stand and pivot, but the resident fell to the floor. The incident resulted in the resident sustaining a right femur fracture, as confirmed by x-ray. The CNA's actions were in direct violation of the resident's care plan and facility protocols, which required two-person assistance and use of a mechanical lift for transfers due to the resident's significant fall risk and physical limitations. Interviews with facility staff, including the LPN, Quality Assurance/Infection Preventionist, Director of Nursing Services, and Executive Director, confirmed that the resident required two-person assistance with a mechanical lift and that the CNA acted alone during the transfer. The CNA was subsequently terminated for failure to follow policy and procedure. The incident was identified as affecting one of four sampled residents reviewed for accidents.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private meeting space for the monthly Resident Council meetings, as required by their own policy. Observations revealed that the meetings were held in the dining area, where there was no signage to indicate a meeting was in progress, and staff members entered the room to access the employee break room. During these meetings, staff were within hearing distance of the residents' discussions, and kitchen staff continued to work with the doors open. Residents reported that they were not aware the meetings should be held in a private area and did not know staff should not enter during the meetings. Multiple residents confirmed that staff continued to enter the dining room during Resident Council meetings, even when a sign was posted on the door. One resident, with intact cognition as indicated by a BIMS score of 14, stated they had previously informed the facility about this issue. Another resident, with moderate cognitive impairment, also reported that staff entered the dining room to eat lunch during the meetings. The facility's policy required meetings to be scheduled in an area that promotes privacy, but this was not followed, resulting in a lack of privacy for the Resident Council meetings.
Failure to Monitor Psychotropic Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of psychotropic medications for one resident who was admitted with a history of Bipolar disorder and depressive episodes. Upon admission, the resident was prescribed clonazepam for anxiety, escitalopram oxalate for depression, and quetiapine fumarate for Bipolar disorder. Despite facility policy requiring routine review and monitoring of residents on psychotropic medications, there was no evidence that staff monitored or documented the effectiveness or side effects of these medications from the time of admission until nearly a month later. Interviews with facility staff, including the Director of Nursing Services, the South Unit Manager, and a Licensed Practical Nurse, confirmed that there was no order or documentation for monitoring the resident's psychotropic medication use prior to the later date. The medication administration records also showed that while the medications were administered as ordered, there was no documentation of monitoring for side effects or efficacy during this period. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and expected practice regarding psychotropic medication monitoring.
Failure to Develop Comprehensive Care Plans for Dialysis and Pain Management
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with specific clinical needs. One resident with end stage renal disease and dependent on hemodialysis was admitted with orders for dialysis three times per week, but there was no evidence of a care plan addressing dialysis in the resident's records. The MDS Coordinator acknowledged that a dialysis care plan is typically completed but was unsure why it was missed in this case. The Executive Director confirmed the expectation that a dialysis care plan should have been in place for this resident. Another resident with a diagnosis of chronic pain, moderate cognitive impairment, and active orders for both scheduled and as-needed oxycodone with acetaminophen, also lacked a care plan addressing pain management. The MDS Coordinator could not locate a pain-related care plan for this resident and did not know how it was missed. Both the Executive Director and the Director of Nursing Services stated their expectations that care plans should be completed to address residents' needs, including pain management.
Failure to Monitor Anticoagulant Medication for Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of an anticoagulant medication for a resident with a history of venous insufficiency and thrombocytopenia. The resident was admitted and prescribed apixaban, an anticoagulant, with orders to administer the medication for blood clot prevention. However, there was no order in place for staff to monitor the resident for side effects or efficacy of the anticoagulant until nearly a month after the medication was started. Review of the medication administration record (MAR) confirmed that while the medication was administered as ordered, there was no documentation of monitoring for side effects or effectiveness during this period. Interviews with the Director of Nursing Services (DNS), the South Unit Manager, and a Licensed Practical Nurse confirmed that monitoring for anticoagulant use should have been documented but was not done prior to the addition of the monitoring order. The DNS and other staff acknowledged the absence of both an order and documentation for monitoring the resident for adverse reactions or effectiveness of the anticoagulant medication until the oversight was identified and corrected.
Call Light Not Kept Within Reach for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident's call light was not kept within reach, contrary to facility policy and the resident's care plan. The resident, who had a diagnosis of autistic disorder and severe cognitive impairment as indicated by a BIMS score of 7, was admitted with a history of falls and had interventions in place requiring the call light to be accessible. Multiple observations showed the call light wrapped around the bed enabler, out of the resident's reach, and both the resident and staff confirmed that the resident could not access the call light when needed. The resident reported that staff typically left the call light in this inaccessible position, and staff interviews confirmed this was not in accordance with expected practice. Staff, including a CNA and an LPN, acknowledged that the call light should have been within the resident's reach and that the resident was unable to reposition it independently. The DON and Executive Director both stated their expectation that call lights be accessible to residents at all times and that staff should check the call light's placement during each room entry. Despite these expectations and documented interventions, the call light was repeatedly found out of reach during the survey.
Failure to Timely Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to ensure that staff reported an allegation of abuse involving a resident with a history of dysarthria following cerebral infarction. The resident, who was cognitively able to make daily decisions with modified independence, alleged that a registered nurse pushed and cursed at them during a skin examination. The resident reported this incident to a family member, who then informed the unit manager. However, the registered nurse involved did not report the allegation to any supervisor or manager as required by facility policy. Facility policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made, to the administrator and appropriate authorities. In this case, the facility did not become aware of the allegation until the family member reported it the following morning, resulting in a delay in notifying the state survey agency. Interviews confirmed that the nurse did not follow the required reporting procedures, and the director of nursing services acknowledged that the allegation should have been reported within the specified timeframe.
Failure to Interview Key Staff in Sexual Abuse Allegation Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident with intact cognition and a diagnosis of acute chronic diastolic heart failure. The allegation, reported by a hospital case manager, stated that a male staff member inserted his thumb into the resident's rectum multiple times while a female staff member spanked the male staff member. The resident could not specify the exact date and time of the incident but indicated it occurred late at night. The facility's abuse prevention policy required an investigation to be initiated for any findings of potential abuse or neglect, including determining cause and effect and protecting the alleged victim during the investigation. Despite identifying a male CNA who worked the relevant shifts, the facility's investigation file contained no evidence that any male staff were interviewed. The Executive Director acknowledged that although a male staff member was identified, there was no documentation of attempts to contact him, nor was this information included in the investigation report. The identified CNA confirmed he was not contacted or informed about the investigation. The Director of Nursing Services stated that she would have expected any involved male staff to be interviewed or contacted as part of the investigation.
Failure to Provide Prescribed Medication Due to Ordering Lapse
Penalty
Summary
The facility failed to provide prescribed medication to a resident with a diagnosis of anxiety disorder. The resident was admitted with an order for alprazolam 0.5 mg at bedtime for anxiety. Documentation in the medication administration record (MAR) showed that the medication was not administered on multiple occasions, with staff using a code indicating 'other, see progress notes.' Progress notes from several LPNs consistently indicated that the alprazolam was either not available, not in stock, or still awaited from the pharmacy. The pharmacy delivery records showed no evidence that the medication was received for the resident during the relevant period. Interviews with nursing staff revealed that they were aware the medication was not available and that it had not been delivered, but they did not take further action beyond waiting for the medication. One LPN stated she did not contact anyone and simply waited for the medication. The pharmacist confirmed that the pharmacy never received an order for alprazolam for the resident, and the Director of Nursing Services stated the order was never faxed to the pharmacy. The Executive Director stated that nurses were expected to follow up with the pharmacy and report missing medications to the DNS, but this did not occur.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure proper documentation and assessment of a resident's skin condition, specifically regarding a rash in the perineal area. The resident, who had a history of hemiplegia, congestive heart failure, diabetes mellitus, atrial fibrillation, and gastrointestinal diseases, was admitted with intact skin and no noted pressure injuries. However, the medical record contained no evidence of skin concerns in the perineal area, despite later hospital documentation indicating the presence of a perineal rash. Statements from a CNA revealed that she observed a white rash, and later a white and pinkish-red rash, in the resident's perineal area on two separate occasions. Each time, she reported her findings to different LPNs, who provided cream for application but did not document the skin issue or notify a physician. Interviews with the involved LPNs showed a lack of recall or recognition of any significant skin issues, and no documentation was found regarding the reported rash. The DON confirmed that there was no documentation of skin issues in the resident's record and stated that nurses were expected to assess and document any reported changes. The Executive Director also stated that nurses were expected to document their responses to CNA reports. The lack of documentation and follow-up on the reported skin condition led to the deficiency.
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What surveyors actually found near you
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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 Mobile
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gulf Coast Health And Rehabilitation, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Knollwood Healthcare | 4.1 mi | — | 9 | 0 |
| Lynwood Rehabilitation And Healthcare Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Springhill Senior Residence | 6.5 mi | ★★★★★ | 0 | 0 |
| Crowne Health Care Of Springhill | 6.7 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.