Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Falkville Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility's Administrator failed to ensure abuse policies were implemented, including reporting and investigating suspected abuse and implementing protective measures. The Administrator made a decision on two cognitively impaired residents' capacity to consent to sexual contact without proper policy and procedure, leading to unreported and uninvestigated incidents.
The facility failed to protect residents from sexual and verbal abuse by another resident on the Memory Care Secured Unit (MCSU). A resident with dementia exhibited sexually inappropriate behaviors towards other residents, including entering rooms, disrobing in public, and making sexual comments. Despite these behaviors being documented, the facility did not report or investigate the incidents, nor did they implement protective measures. The facility also failed to assess the capacity of residents to consent to sexual activity.
The facility failed to establish and implement policies to prevent sexual abuse, leading to multiple incidents of inappropriate sexual behavior by a cognitively impaired resident. The administrator used an unsanctioned questionnaire to assess consent without proper guidelines, and no protective measures were implemented.
A resident exhibited inappropriate sexual behavior towards other residents on multiple occasions, but these incidents were not reported to the Administrator or the State Agency as required by the facility's abuse policy. This failure to report prevented timely investigation and intervention, leaving other residents at risk.
A resident exhibited repeated inappropriate sexual behavior towards other residents, which was reported by staff but not investigated by the Administrator or Director of Nursing. This failure to investigate allowed the behavior to continue, putting other residents at risk.
A resident exhibited pain over two days, but the physician was not notified until the second day, and the family was not informed about ordered X-rays. Staff interviews and Progress Notes confirmed the lack of timely notifications, violating facility policies.
A facility failed to assess and manage a resident's pain daily, especially after a fall. Despite exhibiting facial grimacing and complaining of pain, the resident was not medicated, and no pain assessments were documented. X-rays later revealed fractures, leading to a hospital transfer.
The facility failed to meet the nutritional needs of residents on Pureed, Regular, and Mechanical Soft diets by serving incorrect portion sizes of meals on two consecutive days. This discrepancy was observed during supper service, where the cooks used smaller scoops than required, resulting in residents not receiving the necessary calories and nutrients as per the menu guidelines.
A resident with Vitamin B and D deficiencies did not receive whole milk at meals as ordered by the physician. Despite having whole milk available in gallon containers, the dietary staff failed to pour it into cups, leading to non-compliance with physician orders.
Failure to Implement Abuse Policies and Investigate Allegations
Penalty
Summary
The facility's Administrator failed to provide oversight to ensure the facility's abuse policies were implemented. This included not reporting suspected abuse, not investigating documented allegations of abuse, and not implementing protective measures for residents. Facility staff documented occurrences of potential abuse in a resident's medical record over a period of time, but there was no evidence that these occurrences were reported, investigated, or that protective measures were implemented. When the Administrator became aware that two cognitively impaired residents needed to be assessed for their capacity to consent to sexual contact, the Administrator made a decision on the residents' capacity to consent without a policy and procedure in place. This decision was made without ensuring the assessment was completed accurately and interpreted ethically and without conflict of interest. Based on the Administrator's determination that the residents were in a consensual relationship, the incident was not reported or investigated, and no protective measures were implemented. Interviews with the Director of Nursing, Social Service Director, and other staff revealed that the incident involving inappropriate touching between the two residents should have been reported and investigated as potential sexual abuse. The Administrator admitted that an investigation should have been conducted but did not think immediate safety measures were needed because she believed the residents were consenting. The failure to report and investigate the incident, as well as to implement protective measures, was a significant oversight that had the potential to affect all residents in the facility.
Removal Plan
- The facility's Administrator failed to ensure the facility's Abuse policies were implemented, including reporting, protection, and investigation of abuse allegations or suspected abuse. The facility Administrator conducted an assessment without a policy supporting the ability to conduct a consent assessment and made the decision of RI #13 and RI#19 capacity to consent.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating.
- The Administrator was in-serviced on revised Abuse Policy to include when any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record.
- Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and Case Manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- No other incidents regarding not reporting timely or investigating allegations of abuse were noted through the staff and resident interviews.
- Corporate QAPI completed to ensure that 1 member of the corporate team, either the Executive VP, VP of operations, or Nurse Consultant will be in the facility to ensure operational and clinical meetings are being held and to provide oversight of Administrator's management practices (to include abuse reporting, investigating allegations of abuse).
Failure to Protect Residents from Sexual and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from sexual and verbal abuse by another resident on the Memory Care Secured Unit (MCSU). Resident Identifier (RI) #13, who had dementia, exhibited sexually inappropriate behaviors towards other residents, including entering residents' rooms, disrobing in public, and making sexual comments. Despite these behaviors being documented in RI #13's medical record, the facility did not report or investigate the incidents, nor did they implement protective measures to safeguard other residents. The facility also failed to assess the capacity of residents on the MCSU to consent to sexual activity. RI #13's behaviors were noted to have worsened over time, with multiple incidents of inappropriate sexual conduct documented. These included touching another resident's upper thigh, making sexual comments, and attempting to engage in sexual activity with other residents. Staff members, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), reported these incidents to their supervisors, but no investigations were conducted, and no protective measures were put in place. The Director of Nursing (DON) and other administrative staff were not notified of these incidents, which were considered abusive given the residents' cognitive impairments. Interviews with staff and review of progress notes revealed that the facility's failure to act on these incidents put residents at risk. The facility's policy on abuse did not provide clear guidelines on determining residents' capacity to consent to sexual activity. The facility's inaction and lack of supervision allowed RI #13's behaviors to continue, causing potential harm to other residents. The Immediate Jeopardy (IJ) was identified, and the facility was found to be non-compliant with the requirement to protect residents from abuse, neglect, and exploitation.
Removal Plan
- The facility failed to implement protective measures and provide supervision to residents on the Memory Care Secured Unit (MCSU) after identifying RI #13, a male resident with dementia, was exhibiting sexual inappropriate behaviors towards staff and other residents. No residents on the MCSU were properly assessed for the capacity to consent to sexual activity.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding ensuring residents are kept safe from all types of abuse and neglect. This in-service was completed, and no concerns were noted.
- Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
- Progress notes all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no abuse allegations have gone unreported. No incidents or issues noted in these notes. This review of note was completed.
- All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right to be free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. The administrator and don were in-serviced on (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
- Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. New hires will be educated on the new revision of the abuse policy.
- DON/Designee completed an audit to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
Failure to Implement Policies to Prevent Sexual Abuse
Penalty
Summary
The facility failed to establish and implement policies and protocols to prevent sexual abuse, including a protocol to identify when, how, and by whom determinations of capacity to consent to sexual contact would be made. This failure was highlighted by the case of a resident in the Memory Care Secured Unit (MCSU) who had a history of escalating sexual behaviors. Despite multiple documented incidents of inappropriate sexual behavior, the facility did not report, investigate, or implement protective measures to safeguard other residents from potential abuse. The resident in question, identified as having moderate to severe cognitive impairment, exhibited inappropriate sexual behaviors towards other residents on several occasions. These behaviors included rubbing, grabbing, and making verbal sexual remarks. On one occasion, the resident was found touching another resident's upper thigh in a private room. The facility's administrator used an unsanctioned questionnaire to assess the capacity of both residents to consent to sexual contact, without any supporting policy or guidelines to ensure the accuracy of this determination. Interviews with facility staff revealed that the administrator was not notified of several incidents of inappropriate behavior, and no investigation or safety measures were put in place. The facility's policy on abuse was found to be inadequate, lacking specific guidelines on how to handle situations involving residents' capacity to consent to sexual activity. This deficiency had the potential to affect all residents in the MCSU, as the facility failed to protect them from potential sexual abuse.
Removal Plan
- The facility failed to implement an abuse policy and procedure to protect residents on the Memory Care Secured Unit from abuse including affectionate physical touching, and verbal sexual statements made to female residents about their body parts. Abuse policy was instituted.
- The facility further failed to develop and implement a policy and to ensure resident's capacity to consent to sexual contact prior to the Administrator deciding RI #19 and RI #13, residents residing on the MCSU, could consent to sexual contact.
- Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record).
- This had the potential to affect all residents on the memory care secured unit. No residents are engaging in sexual conduct currently. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity.
- Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, an immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity. New hires will be educated on the new revision of the abuse policy.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
Failure to Report Suspected Abuse by Resident
Penalty
Summary
The facility failed to immediately report incidents of suspected abuse by a resident identified as RI #13 to the Administrator, resulting in a failure to investigate and protect other residents on the Memory Care Secured Unit (MCSU). RI #13 exhibited inappropriate sexual behavior towards other residents on multiple occasions, including making sexual comments, touching female residents inappropriately, and entering female residents' rooms with inappropriate intentions. These incidents occurred on several dates, including 01/03/2024, 01/04/2024, 01/08/2024, 01/11/2024, and 01/12/2024, but were not reported to the Administrator or the State Agency as required by the facility's abuse policy. The facility's policy mandates that any incident or allegation of abuse must be reported immediately to the Administrator, who is then responsible for reporting to the State Agency within two hours. However, interviews with staff members, including LPNs and the DON, revealed that the incidents involving RI #13 were either not reported at all or were reported to supervisors who did not escalate the reports to the Administrator. This lack of reporting prevented timely investigation and intervention, leaving other residents at risk. The failure to report these incidents was confirmed through interviews with the DON and the Administrator, who both stated that they were not informed of the incidents involving RI #13. The DON acknowledged that the inappropriate touching of a female resident by RI #13 should have been considered sexual abuse and reported to the State Agency. The Administrator also confirmed that the incidents were not reported to her, which was a violation of the facility's abuse policy. This deficiency was identified during the investigation of a complaint and was determined to have the potential to affect all residents on the MCSU.
Removal Plan
- Immediate action(s) taken for the resident(s) found to have been potentially affected include: The facility failed to immediately report incidents of suspected abuse by RI #13 to the Administrator which resulted in failure of the Administrator to investigate and protect female residents residing on the Memory Care Secured Unit (MCSU).
- According to the facility's abuse policy facility staff must immediately report to the Administrator any incident or allegation that could constitute an instance of abuse. The staff is to immediately protect or safeguard the resident in question and any other residents at potential risk of the alleged abuse. The administrator is to report to ADPH the allegation of suspected abuse or neglect within 2 hours of being notified and complete the investigation within 5 business days.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating according to F-609. This includes safeguarding the identified residents at risk for abuse or potential for abuse and reporting to ADPH according to the reporting guidelines from ADPH.
- Identification of other residents having the potential to be affected: This had the potential to affect all residents. Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- Actions taken/systems to be put into place to reduce the risk of future occurrences include: Education was completed with staff members in person and staff members via telephone; Education was completed when to report, who to report and what to report.
- According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. New hires will be educated on the new revision of the abuse policy.
- DON/Designee completed an audit with staff members in person and staff members via telephone; Education was completed on abuse policy, when to report, who to report and what to report. According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. Also, to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
- Facility requests for IJ removal plan to be effective.
Failure to Investigate Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate incidents of abuse by a resident identified as RI #13, which led to repeated inappropriate sexual behavior towards other residents. The incidents began on 01/03/2024, when RI #13 exhibited inappropriate sexual behavior, and continued on multiple occasions, including making sexual comments and touching a female resident's thigh. Despite these behaviors being reported by an LPN to the Administrator (ADM) and Director of Nursing (DON), there was no evidence that these incidents were investigated as required by the facility's abuse policy. Interviews with the ADM and DON revealed that they were either not made aware of the incidents or did not have specific details about them. Both acknowledged that the incidents should have prompted an investigation. The ADM admitted that any type of allegation of abuse would necessitate an investigation, while the DON confirmed that she should have been notified to make a judgment call on how to proceed. The lack of investigation allowed RI #13's inappropriate behavior to continue, putting other residents at risk. Further review of RI #13's progress notes and additional interviews with staff, including another LPN and the Social Service Director (SSD), confirmed that the incidents were not properly communicated or investigated. The SSD was unaware of specific incidents and emphasized the importance of reporting such behaviors to the Administrator for investigation. The Regional Director of Health Services (RDHS) also highlighted the need for administrative staff to be aware of incidents to ensure proper follow-up. The failure to investigate these incidents resulted in a finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation.
Removal Plan
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations. Administrator and DON were instructed on when to initiate an abuse investigation and how the investigation will be conducted and reviewed.
- Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations.
- DON/Designee completed an audit with staff to ensure staff were made aware of what to report, when to report and who to report to. This is to ensure the administrator could complete a thorough investigation. This was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). QAPI Discussed RI#13 and the incident surrounding this incident Discussed in QAPI, Administrator would investigate thoroughly all allegations of abuse timely, investigate immediately by way of staff interviews, resident medical records, and will be reviewed by Director of Health Services and/or VP of Operations before submitting.
- Facility requests for IJ removal plan to be effective. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations.
Failure to Notify Physician and Family of Resident's Pain and Medical Orders
Penalty
Summary
The facility failed to notify the physician and family of a resident's pain and subsequent medical orders. The resident exhibited facial grimaces indicating pain on two consecutive days, 11/26/2023 and 11/27/2023, but the physician was not notified until the second day. Additionally, the resident's family was not informed about the order for X-rays on 11/27/2023, despite the facility's policies requiring such notifications. The resident, identified as RI #14, had a care plan in place for pain management, which included notifying the physician of any changes in pain symptoms. Despite this, the resident's facial grimaces and complaints of pain were not communicated to the physician promptly. The resident's Progress Notes confirmed the presence of pain and bruising, but there was no documentation of physician notification until the second day of pain complaints. Interviews with staff, including LPNs and the Director of Nursing, corroborated the failure to notify the physician and family as required. The physician also confirmed that he expected to be notified about any pain issues and that such notifications should be documented in the Progress Notes. The deficiency was identified during an investigation of a complaint/report and affected one of five residents sampled for falls.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to ensure that a resident's pain was assessed on a daily basis, especially after the resident fell. According to the facility's policy, an ongoing assessment of pain utilizing either a numerical scale of 0-10 or a verbal descriptor scale should be conducted daily and documented on the Medication Administration Record (MAR). However, upon review of the resident's MAR, there was no evidence that the resident's pain was being assessed daily, nor was there a physician's order for pain management. This deficiency was particularly concerning given that the resident exhibited facial grimacing, a symptom of pain, on multiple occasions following the fall, yet was never medicated for the pain. The resident, who had a history of falls, was originally admitted to the facility on a previous date and readmitted on another date. The resident's care plan included interventions to observe for worsening pain symptoms and notify the physician of changes, as well as to assess pain daily using a 1-10 scale. Despite these interventions, the resident's pain was not assessed daily, and there was no documentation of pain assessments on the MAR. The resident exhibited facial grimacing when his/her leg was moved and complained of pain when turned to the left side, yet no pain medication was administered. X-rays later revealed that the resident had a fracture of the right hip and left and right femurs, necessitating a transfer to the hospital for treatment. Interviews with multiple Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that pain assessments were supposed to be completed every shift and documented on the MAR. However, there was no evidence that these assessments were conducted for the resident on several dates. The DON acknowledged that the resident's pain was not managed appropriately and that the physician should have been notified when symptoms of pain were observed. The facility's failure to assess and manage the resident's pain appropriately led to the resident suffering from untreated pain and subsequent fractures that were only identified days after the initial fall.
Failure to Meet Nutritional Needs of Residents
Penalty
Summary
The facility failed to ensure that the nutritional needs of residents on Pureed, Regular, and Mechanical Soft diets were met according to the established menus. On 04/24/2024, residents receiving Pureed diets were served a 3-ounce portion of pureed Lasagna instead of the required 6-ounce portion. This discrepancy was observed during the resident tray line for supper, where the AM Cook used a smaller, green-handled scoop instead of the appropriate #6 scoop. The AM Cook acknowledged the error, attributing it to a routine practice of using the green-handled scoop for pureed meats. The Dietary Manager confirmed that residents on Pureed diets did not receive a full serving of Lasagna, thus not meeting their nutritional needs as per the menu guidelines. The Registered Dietitian (RD) also confirmed that the residents were not given all the calories or nutrients required by the menu due to the incorrect portion size served. On 04/25/2024, a similar issue was observed with the serving of hot dogs for supper. Residents on Regular, Mechanical Soft, and Pureed diets were served portions that did not meet the menu requirements. The PM Cook used a #12 scoop, which is smaller than the required #10 scoop, resulting in portions less than the 3 ounces specified by the menu. The PM Cook and the Dietary Manager both acknowledged the error, with the Dietary Manager noting that the residents were not getting enough protein. The RD confirmed that the residents on Regular, Mechanical Soft, and Pureed diets were not receiving the necessary calories and nutrients due to the incorrect portion sizes served. The facility's policies for Menus and Adequate Nutrition and Nourishment, dated 02/20/2024, were not followed, leading to these deficiencies. The policies state that menus should meet the nutritional needs of residents and be reviewed by a dietitian for nutritional adequacy. However, the observed practices on 04/24/2024 and 04/25/2024 did not align with these policies, resulting in residents not receiving the appropriate portions of their meals. This failure had the potential to affect all 84 residents receiving meals from the facility's kitchen.
Failure to Provide Whole Milk as Ordered
Penalty
Summary
The facility failed to ensure that a resident received whole milk at each meal as ordered by the physician. This deficiency was observed during the dinner meal on 04/24/2024 and the lunch meal on 04/25/2024. The resident, who had Vitamin B and Vitamin D deficiencies, was supposed to receive whole milk with all meals according to the April 2024 Medication Review Report and the resident's tray cards. However, during these meals, the resident was not served whole milk as required by the physician's orders. The issue arose because the facility's food vendor could not provide individual cartons of whole milk due to a packaging problem. Despite having whole milk available in gallon containers, the dietary staff did not pour the milk into cups for the resident. Both the Administrator and the Dietary Manager confirmed that whole milk was available in the facility and could have been served in cups. The Dietary Manager admitted that the dietary staff probably did not think of pouring the milk into cups and had to be instructed to do so. The Registered Dietitian confirmed that not serving whole milk as ordered meant the physician's orders were not being followed, and the resident was not receiving the prescribed intervention.
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Illustrative
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.
Illustrative
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Nursing homes near Falkville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summerford Health And Rehab, Llc | 1.1 mi | — | 0 | 0 |
| Cullman Health Care Center | 12.7 mi | — | 0 | 0 |
| Folsom Rehabilitation And Healthcare Center | 14 mi | — | 0 | 0 |
| Decatur Health & Rehab Center | 15 mi | — | 0 | 0 |
| Woodland Village Rehabilitation And Healthcare Cen | 15.4 mi | — | 0 | 0 |
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