Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Huntsville Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate MDS Coding for PASRR Serious Mental Illness: The facility failed to accurately code PASRR Level II serious mental illness status on MDS assessments for three residents. Each resident had diagnoses such as schizophrenia, major depressive disorder, bipolar disorder, PTSD, or impulse disorder, and each had a PASRR Level II outcome stating the resident met criteria for serious mental illness, yet the MDS assessments were coded “No” for that item. The MDS Coordinator confirmed the assessments were inaccurate.
A resident with HTN, CHF, osteopenia, and morbid obesity was identified as being at risk for falls due to weakness, but the comprehensive care plan was not revised after a transfer-related fall. The incident report noted the resident’s knee became weak during a bed-to-wheelchair transfer and the resident was lowered to the floor by a PTA and CNA; although a Hoyer lift was listed as a new intervention, the DON confirmed the care plan was not updated to include it.
Improper storage of insulin pens was identified on a skilled hall med cart when 2 Lispro pens and 2 Lantus pens were found in use and not dated. Facility policy required meds to be stored per manufacturer guidance, and the ADON and DON confirmed the pens were not stored properly.
An ADON failed to follow infection control practices during medication administration. She dropped a cap from an OTC medication bottle onto the floor, picked it up, replaced it without sanitizing the cap or washing her hands, and split a medication in half using bare hands before placing the medications in a cup and administering them to a resident. The DON confirmed the improper infection control practices.
The facility failed to report COVID-19 infections for seven residents to the local health department in a timely manner. Additionally, two COVID-19 positive residents were allowed to participate in a smoking activity with two COVID-19 negative residents, violating infection control practices. A CNA provided care to a COVID-19 positive resident without proper PPE, and staff did not offer hand hygiene assistance to several residents before meals.
A resident with an indwelling urinary catheter had their dignity compromised when the facility failed to cover their urinary catheter collection bag, leaving it visible from the room's door. The facility's policy requires such bags to be placed in privacy bags, but this was not adhered to, as confirmed by an LPN and the DON.
A resident with cognitive impairments and hemiplegia was found to have a spiral fracture of the distal tibia, which the facility failed to report as an injury of unknown origin. Despite the facility's policy requiring such injuries to be reported, the staff assumed the injury was caused by the resident's leg getting caught under a wheelchair pedal, although there was no witness or documentation to support this. The resident, unable to communicate due to expressive aphasia, had no known incidents or falls, and the facility's investigation lacked evidence to explain the injury.
A resident in an LTC facility, who required assistance due to blindness and other conditions, did not receive proper nail care as part of ADL. Despite the facility's policy requiring routine nail cleaning, observations showed the resident had long, unclean nails. Staff interviews confirmed that nail care was supposed to be done during bathing, but the resident's needs were neglected.
A resident was found with unsecured smoking supplies and medications at their bedside, contrary to the facility's policy requiring such items to be stored securely. The resident, who was receiving treatment for COPD and nicotine dependence, admitted to smoking outside the facility with their daughter, who had brought the cigarettes and lighter. Staff interviews revealed a lack of awareness about the resident's possession of these items, highlighting a deficiency in maintaining a safe environment.
The facility failed to properly store nebulizer masks for two residents, leading to a deficiency in respiratory care. A resident with COPD and other conditions was observed with an uncovered nebulizer mask, confirmed by the DON. Another resident, also with COPD, was seen multiple times with an uncovered mask, confirmed by both the resident and an LPN. The DON acknowledged the staff's failure to follow the facility's policy requiring masks to be covered when not in use.
A facility's ineffective QAPI program led to a deficiency when medications were found at a resident's bedside, despite the resident not being assessed for self-administration. The resident, with multiple diagnoses including COPD, was cognitively intact. The facility had previously been cited for a similar issue, and despite implementing a Resident Advocate Program to prevent such occurrences, the medications were not observed during routine checks.
A resident with a history of medical and psychological conditions was found hoarding medications, including prescribed and over-the-counter drugs, due to the facility's failure to implement a comprehensive care plan. Despite being cognitively intact, the resident engaged in manipulative behaviors involving medication, which were not adequately addressed. The facility's policy required comprehensive care plans, but the resident's plan lacked updates to address these behaviors, posing a risk to the resident and others.
A resident with a history of various medical conditions was able to hoard medications due to inadequate supervision during medication administration. The resident's manipulative behavior, including delaying the medication process, led to medications being left at the bedside or not properly observed by staff. This resulted in the discovery of a significant quantity of hoarded pills, placing the resident and others at risk.
A resident in an LTC facility was able to hoard medications due to the failure of medication nurses to ensure the resident swallowed all medications when administered. Despite being cognitively intact, the resident was found with medications in their room on multiple occasions. The facility's policy required nurses to observe residents swallowing medications, but this was not consistently followed, leading to inaccurate documentation and an Immediate Jeopardy situation.
A resident was found self-administering medications without an assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident hoarded medications, including pain medication and muscle relaxants, over time. Staff interviews revealed that medications were left with the resident without proper authorization, and the facility failed to follow its self-administration policy.
The facility failed to maintain a homelike environment in several resident rooms due to unclean wheelchairs and personal furniture, resulting in foul odors. The DON confirmed that the cleaning schedule for incontinent residents' wheelchairs was not followed, and personal recliners were not adequately cleaned as part of the housekeeping schedule.
Inaccurate MDS Coding for PASRR Serious Mental Illness
Penalty
Summary
The facility failed to ensure MDS assessments were accurate for 3 residents reviewed for MDS assessments. Review of the MDS 3.0 RAI Manual Version 19.1 showed that residents covered by the Level II PASRR process may require certain care and services, and that the MDS should code “yes” when PASRR Level II screening determined the resident has a serious mental illness. Medical record review showed Resident #21 was admitted with diagnoses of Schizophrenia and Major Depressive Disorder and had a PASRR Level II outcome stating the resident met criteria for serious mental illness, yet the significant change MDS assessment coded that the resident considered by the state Level II PASRR process to have a serious mental illness was “No.” Medical record review also showed Resident #31 was admitted and later readmitted with diagnoses including Major Depressive Disorder, Impulse Disorder, and Post Traumatic Stress Disorder, and had a PASRR Level II outcome stating the resident met criteria for serious mental illness, yet the annual MDS assessment coded that the resident considered by the state Level II PASRR process to have a serious mental illness was “No.” Resident #66 was admitted with diagnoses including Major Depressive Disorder, General Anxiety Disorder, Bipolar Disorder, Schizophrenia, and Delirium, and had a PASRR Level II outcome stating the resident met criteria for serious mental illness, yet the annual MDS assessment coded that the resident considered by the state Level II PASRR process to have a serious mental illness was “No.” During interview, the MDS Coordinator confirmed these three MDS assessments were inaccurate.
Failure to Update Fall Care Plan After Transfer-Related Fall
Penalty
Summary
The facility failed to revise Resident #2’s comprehensive care plan to include a fall intervention after a fall event. Resident #2 was admitted with diagnoses including hypertension, congestive heart failure, osteopenia, and morbid obesity, and the comprehensive care plan dated 8/23/2023 identified the resident as at risk for falls related to weakness. A facility fall incident report dated 8/14/2025 documented that while transferring the resident from bed to wheelchair, the resident’s knee became weak and the resident was lowered to the floor by a PTA and CNA. The incident report listed a new intervention of using a Hoyer lift for transfers, but continued review showed no new intervention had been added to the care plan after the fall. During interview, the DON confirmed the comprehensive care plan had not been revised to include use of a Hoyer lift with transfers after the fall.
Improper Storage of Insulin Pens
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when 4 insulin pens on 1 of 3 medication carts were found improperly stored. Facility policy stated medications were to be stored according to manufacturer recommendations. Manufacturer guidelines for insulin lispro stated opened prefilled pens could only be stored at room temperature and must be discarded after 28 days, and guidelines for Lantus stated all containers in use must be discarded after 28 days. During observation of the skilled hall medication cart, 2 Lispro pens and 2 Lantus pens were found in use and undated, and pharmacy delivery dates showed the pens were not beyond the 28-day use period. The ADON confirmed the 4 insulin pens were in use and not stored properly on the skilled unit medication cart, and the DON stated it was her expectation that insulin pens be dated when opened.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to follow infection control practices during medication administration. During an observation on 11/18/2025 at 7:49 AM, the Assistant Director of Nursing dropped a cap from a bottle of over-the-counter medication onto the floor, picked it up, placed the lid back on the bottle, and did not sanitize the cap or wash her hands. The observation also showed the ADON splitting a medication in half using bare hands, placing all medications in a cup, and administering the medications to Resident #95. During interviews on 11/18/2025 and 11/19/2025, the ADON confirmed the actions observed, and the Director of Nursing confirmed the ADON failed to follow proper infection control practices during medication administration.
Infection Control and Reporting Deficiencies
Penalty
Summary
The facility failed to report new COVID-19 infections for seven residents to the local health department in a timely manner. The Director of Nursing (DON) acknowledged that the positive COVID-19 test results for these residents were not reported until ten days after the tests were conducted. This delay in reporting is a violation of the state Department of Health's requirements for reporting communicable diseases, including COVID-19. Additionally, the facility did not adhere to appropriate infection control practices by allowing two COVID-19 positive residents to participate in a smoking activity with two COVID-19 negative residents. During the observation, it was noted that the residents were not wearing masks and were in close proximity to each other, which contradicts the facility's policy that residents with confirmed COVID-19 should not participate in communal activities and should remain in their rooms unless medically necessary. The facility also failed to ensure proper infection control practices were followed for a resident under transmission-based precautions. A CNA was observed providing care to a COVID-19 positive resident without wearing the required personal protective equipment (PPE), such as a gown, gloves, and eye protection. Furthermore, staff did not offer hand hygiene assistance to several residents before meals, which is a breach of the facility's hand hygiene policy.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to protect the dignity of a resident by not covering a urinary catheter collection bag. The facility's policy on promoting resident dignity requires that urinary catheter bags be placed in privacy bags. However, during an observation, it was noted that the urinary collection bag of a resident was uncovered and visible from the door of the resident's room. This observation was confirmed by an LPN who acknowledged that the bag was not covered with a dignity bag. The resident involved was admitted with diagnoses including Bladder Neck Obstruction, Benign Prostatic Hyperplasia, and Major Depressive Disorder. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview for Mental Status assessment. The Director of Nursing confirmed that it was her expectation for all urinary catheters to have privacy bags, and acknowledged that the resident's dignity was compromised when the catheter bag was left uncovered.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state designated authorities for a resident, identified as Resident #24, who was found to have a comminuted spiral fracture of the distal tibia. The facility's policy requires that all unexplained injuries be investigated and reported if they meet certain criteria, such as being suspicious due to the extent or location of the injury. Despite these requirements, the facility did not report the injury, as they believed it was caused by the resident's leg getting caught under the wheelchair pedal, although there was no witness or documentation to support this claim. Resident #24, who has a history of cerebrovascular accident, hemiplegia, and cognitive impairments, was noted to have pain, redness, and swelling in the right lower extremity. An x-ray confirmed a spiral fracture, and the resident was sent to the emergency room for further evaluation. The resident, who has expressive aphasia, was unable to communicate the cause of the injury, and staff interviews revealed no known incidents or falls that could explain the fracture. The facility's investigation did not find any witnesses or evidence to support the assumption that the injury was caused by the wheelchair pedal. Interviews with the facility's Administrator, DON, and Risk Manager revealed that the injury was not reported because they believed it was not of unknown origin, based on the resident's history of not using the wheelchair foot pedal. However, the investigation lacked documentation or witness statements to substantiate this belief. The facility's failure to report the injury as required by their policy and state regulations constitutes a deficiency in their handling of potential abuse or neglect cases.
Failure to Provide Nail Care During ADL
Penalty
Summary
The facility failed to provide adequate nail care during Activities of Daily Living (ADL) for a resident who required assistance. The facility's policy on ADL care, which includes nail care, mandates routine cleaning and inspection of nails by nursing staff. However, observations and interviews revealed that a resident, who was cognitively intact but required assistance due to blindness and other medical conditions, had long, rough fingernails with a brown substance underneath. The resident expressed a desire to have his nails clipped, indicating that staff had not attended to this need recently. The resident's medical records showed that he had not received a bath since a specific date, and during multiple observations, his nails remained uncleaned. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), confirmed that nail care was supposed to be part of the bathing routine. The Director of Nursing (DON) acknowledged that nail care should be performed during showers and confirmed that the resident was not receiving thorough ADL care, as evidenced by the neglected nail condition.
Failure to Secure Smoking Supplies and Medications
Penalty
Summary
The facility failed to ensure that smoking supplies and medications were properly secured for a resident, leading to a deficiency in maintaining a safe environment. The facility's policy mandates that all smoking products, such as cigarettes and lighters, be kept at the nurse's station and not in the possession of residents. Additionally, medications are to be stored in locked compartments unless a resident has been assessed as safe to self-administer. However, during an observation, it was found that a resident had a cigarette lighter, a pack of cigarettes, and medications at their bedside, which were not secured as per the facility's policy. The resident in question was admitted with multiple diagnoses, including COPD and nicotine dependence, and was receiving treatment with inhaled medications and a nicotine patch for smoking cessation. Despite the resident's care plan indicating the use of tobacco products, the resident was not currently using tobacco products according to the Minimum Data Set assessment. However, during an interview, the resident admitted to smoking half a cigarette outside the facility with their daughter, who had brought the cigarettes and lighter during a visit. The facility's Director of Nursing confirmed the presence of these items at the resident's bedside and removed them, reiterating the facility's smoking policy to the resident. Interviews with various staff members, including the Director of Nursing, Licensed Practical Nurse, Certified Nursing Assistant, and Activities Director, revealed a lack of awareness regarding the resident's possession of smoking supplies and medications. The staff confirmed that the resident had not participated in smoke times and that smoking supplies were supposed to be secured in the Activities office. The Social Services Director also confirmed that the resident's stepdaughter had brought the cigarettes and lighter during a visit, contrary to the facility's policy. The facility's failure to secure smoking supplies and medications as per their policy resulted in a deficiency in ensuring a safe environment for residents.
Improper Storage of Nebulizer Masks for Residents
Penalty
Summary
The facility failed to ensure proper storage of nebulizer masks for two residents, leading to a deficiency in respiratory care. Resident #11, who was admitted with conditions including Pneumonia, COPD, and Chronic Respiratory Failure, was observed with a nebulizer mask lying uncovered on the bedside table. This was confirmed by the Director of Nursing (DON) during an observation and interview, who acknowledged that the mask should have been stored in a plastic bag when not in use, as per the facility's policy. Similarly, Resident #40, who has diagnoses including COPD and is cognitively intact, was observed on multiple occasions with an uncovered nebulizer mask on the bedside table. Both the resident and a Licensed Practical Nurse (LPN) confirmed the mask was not stored according to policy. The DON reiterated that the expectation was for masks to be covered when not in use, confirming the staff's failure to adhere to the respiratory equipment policy.
Medication Safety Deficiency Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective and ongoing Quality Assurance Performance Improvement (QAPI) program, resulting in a deficiency when medications were found at a resident's bedside. The facility's policy requires that medications be secured unless a resident has been assessed as safe to self-administer. However, during an observation, medications including an Albuterol Sulfate inhaler and a vial of Budesonide Inhalation Suspension were found on the bedside table of a resident who had not been evaluated for self-administration. This oversight occurred despite the facility's implementation of a Resident Advocate Program (RAP) to prevent such issues. The resident involved was admitted with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) and was cognitively intact according to a recent assessment. The facility had previously been cited for a similar deficiency at an Immediate Jeopardy level, indicating a serious risk to resident safety. Despite the RAP program's daily checks, the medications were not observed by the resident's advocate prior to the survey team's arrival, highlighting a lapse in the facility's QAPI program and its processes to ensure medication safety.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, leading to a situation of Immediate Jeopardy. The resident, who had a history of various medical and psychological conditions, was found hoarding medications, including both prescribed and over-the-counter drugs. Despite being cognitively intact, the resident engaged in manipulative behaviors involving medication, such as hoarding and cheeking, which were not adequately addressed in the care plan. The deficiency was identified when the resident was discovered with medications at their bedside, and further investigations revealed that the resident had been ordering and receiving over-the-counter medications online. The facility's policy required comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but the care plan for this resident lacked updates or revisions to address the manipulative behaviors and the accumulation of medications. Interviews with staff, including the DON and Medical Director, confirmed that the facility did not implement appropriate interventions following the discovery of medications at the resident's bedside. The failure to address these issues in the care plan posed a risk not only to the resident but also to other residents in the facility, as there was a possibility of harm if other residents accessed the hoarded medications.
Inadequate Supervision During Medication Administration Leads to Medication Hoarding
Penalty
Summary
The facility failed to ensure adequate supervision during medication administration, leading to a situation where a resident was able to hoard medications. This deficiency was identified through medical record reviews, facility documentation, observations, and interviews. The resident involved had a history of various medical conditions, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Anxiety Disorder. Despite being cognitively intact, the resident was found to have hoarded medications on multiple occasions, which were discovered by staff during routine checks and cleaning activities. The resident's behavior included delaying the medication administration process, which sometimes led to medications being left at the bedside or not being properly observed by the nursing staff. This behavior was noted to be manipulative, as the resident would take a long time to consume medications, creating opportunities to hide or hoard them. On several occasions, staff found medications in the resident's room, including a significant quantity of pills hidden in various places, such as a headphone case and a duffle bag. The resident denied any suicidal or harmful intentions but admitted to hoarding medications over time. Interviews with staff revealed that the resident's medication administration process was time-consuming, often taking up to an hour, which contributed to the oversight. The staff acknowledged that the resident's manipulative behavior and the large number of medications to be administered created challenges in ensuring all medications were consumed. The facility's failure to provide adequate supervision during medication administration placed the resident and potentially other residents at risk, as there was a possibility of other residents accessing the hoarded medications.
Failure to Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to provide a complete and accurate record of a resident's medication administration, which led to an Immediate Jeopardy situation. The medication nurses did not ensure that the resident swallowed all medications when administered, resulting in the Medication Administration Record (MAR) documenting medications as administered that were not actually taken by the resident. This oversight allowed the resident to hoard medications in their room, creating a potential risk for the resident and others in the facility. The resident involved had a history of multiple diagnoses, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Major Depressive Disorder. Despite being cognitively intact, as indicated by a high score on the Brief Interview for Mental Status (BIMS) assessment, the resident was found to have hoarded medications on multiple occasions. Nursing notes and psychiatric evaluations revealed that the resident had been keeping medications at their bedside and in other personal belongings, such as a headphone case and a duffel bag. Interviews with the Director of Nursing (DON) and other staff confirmed that the facility failed to accurately document the resident's medication administration. The resident reportedly had difficulty taking all medications at once and expressed concerns about potential retaliation if they reported not taking all medications. The facility's policy required nurses to observe residents swallowing medications, but this was not consistently followed, leading to the inaccurate documentation and the resident's ability to hoard medications.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to prevent a resident from self-administering medications without an assessment and a physician's order. The facility's policy requires an interdisciplinary team assessment and a physician's order before a resident can self-administer medications. However, Resident #10 was found with medications at his bedside on multiple occasions without such an assessment or order. The resident, who was cognitively intact, had been hoarding medications, including pain medication, muscle relaxants, and medications for stomach acid, over a long period. The resident was admitted with multiple diagnoses, including Psoriatic Arthritis, Chronic Obstructive Pulmonary Disease, and Bipolar Disorder. Despite being cognitively intact, the resident accumulated medications in his room, which were discovered by staff during routine checks. The resident admitted to hoarding medications and expressed that it was a 'dumb idea.' The facility staff, including the Nurse Practitioner and the Director of Nursing, were aware of the situation but did not ensure that the resident was assessed for self-administration or that a physician's order was obtained. Interviews with facility staff revealed that the resident was allowed to keep certain medications in his room, such as anti-nausea medication and dietary enzymes, even though there was no order for self-administration. The Licensed Practical Nurse admitted to leaving medications with the resident if he did not take them during the medication pass. The Executive Director of Nursing confirmed that the facility did not follow its policy for self-administration of medications, leading to the deficiency.
Failure to Maintain a Homelike Environment Due to Unclean Furniture
Penalty
Summary
The facility failed to maintain a homelike environment free from odors in four resident rooms. Observations and interviews revealed that the source of the foul odors was urine-soaked wheelchairs and personal furniture, such as recliners and rock-n-go chairs, in the residents' rooms. The facility's document on wheelchair cleaning indicated that wheelchairs of incontinent residents were to be cleaned weekly, but there was no documentation of cleaning after September 1, 2023. This lapse in documentation and cleaning was confirmed by the Director of Nursing (DON) during interviews. The DON acknowledged that the system for documenting wheelchair cleaning had been neglected, as the log had been misplaced. Additionally, personal recliners were supposed to be part of the deep cleaning schedule by housekeeping, which was also not effectively implemented. The DON confirmed that the facility had failed to maintain a homelike environment in three resident rooms due to these oversights.
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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) |
|---|---|---|---|---|
| Oneida Nursing And Rehab Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Mccreary County Rehab And | 17.1 mi | ★★★★★ | 0 | 0 |
| Cumberland Village Care | 18.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Morgan County | 22.3 mi | ★★★★★ | 0 | 0 |
| Rocky Top Care Center | 22.7 mi | ★★★★★ | 7 | 0 |
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