Inspection Reports for
Mitchell-Hollingsworth Nursing and Rehabilitation Center
AL, 35630
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident abuse, use of unnecessary psychotropic medications, failure to provide required transfer and bed-hold notices, inadequate fall root cause analysis, improper use of bed rails, and expired medications found in the facility.
Complaint Details
The complaint investigation was substantiated based on findings of resident-to-resident abuse, inappropriate medication use, failure to provide required transfer notices, inadequate fall investigations, improper bed rail use, and expired medication storage.
Findings
The facility was found to have multiple deficiencies including failure to prevent resident-to-resident physical abuse, inappropriate use of atypical antipsychotic medications without proper diagnosis, failure to provide written transfer and bed-hold notices to resident representatives, inadequate investigation of falls, failure to attempt alternatives before using bed rails, and storage of expired medications accessible for resident use.
Deficiencies (6)
Failure to protect residents from abuse including a resident-to-resident physical altercation.
Failure to ensure appropriate diagnosis for use of atypical antipsychotic medication in residents with dementia.
Failure to provide written notice of transfer and bed-hold policies to resident representatives for emergent hospital transfers.
Failure to conduct thorough root cause analysis for resident falls.
Failure to attempt alternatives prior to use of bed rails and lack of documentation of such attempts.
Expired medications (tuberculin purified protein derivative vial) found in medication room refrigerator accessible for resident use.
Report Facts
Sample residents reviewed: 38
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents on 200 hall: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse incident, medication reviews, transfer notices, bed rail use, and expired medication. |
| Quality Improvement Registered Nurse | Quality Improvement Registered Nurse (QIRN) | Interviewed regarding medication reviews, transfer notices, and bed rail use. |
| Licensed Practical Nurse 3 | Licensed Practical Nurse (LPN) 3 | Witnessed resident fall and provided information about fall incident. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse (LPN) 4 | Observed expired medication in medication room refrigerator. |
| Registered Nurse 1 | Registered Nurse (RN) 1 | Described transfer process and documentation for hospital transfers. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident-to-resident abuse at Mitchell-Hollingsworth Nursing & Rehabilitation.
Complaint Details
The complaint investigation found a resident-to-resident physical abuse incident where Resident R220 hit Resident R137 in the face, causing injury. The incident was witnessed by staff, and interventions included immediate separation, treatment, notification of physician and family, and 1:1 care for the aggressor resident. The Director of Nursing confirmed the incident and noted the resident's behavioral issues.
Findings
The facility failed to ensure one of six residents reviewed for abuse was free from abuse, specifically a resident-to-resident physical altercation resulting in injury. Staff intervened immediately, and appropriate assessments and notifications were made.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse and neglect.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the resident-to-resident abuse incident and confirmed the event. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident-to-resident abuse at Mitchell-Hollingsworth Nursing & Rehabilitation.
Complaint Details
The complaint investigation was substantiated based on record review, interviews, and eyewitness accounts confirming a resident-to-resident physical abuse incident involving residents R137 and R220. The incident was witnessed by staff and resulted in injury to R137. The facility intervened and provided care, including 1:1 supervision for R220 and notification of physician and family.
Findings
The facility failed to ensure one of six residents reviewed for abuse was free from abuse, specifically a resident-to-resident physical altercation resulting in injury. The investigation confirmed the incident and identified deficiencies in protecting residents from abuse.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse, neglect, and exploitation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the abuse incident and recalled the event. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident abuse, medication management, transfer notifications, fall investigations, bed rail use, and medication storage at Mitchell-Hollingsworth Nursing & Rehabilitation.
Complaint Details
The complaint investigation was substantiated based on findings of resident-to-resident physical abuse, medication management issues, failure to notify families in writing of transfers, inadequate fall investigations, improper use of bed rails, and expired medication storage.
Findings
The facility was found to have multiple deficiencies including failure to prevent resident-to-resident physical abuse, inappropriate use of psychotropic medications without proper diagnosis, failure to provide written transfer and bed hold notices to resident representatives, inadequate fall root cause analyses, failure to attempt alternatives before using bed rails, and storage of expired medications accessible for resident use.
Deficiencies (6)
Failure to protect residents from all types of abuse including physical abuse between residents.
Failure to ensure appropriate diagnosis for use of atypical antipsychotic medication in residents with dementia.
Failure to provide written notice of transfer and/or bed hold notice to resident representatives for emergent hospital transfers.
Failure to conduct thorough fall root cause analysis for residents who experienced falls.
Failure to attempt alternatives prior to use of bed rails and lack of documentation of such attempts.
Failure to ensure expired medications were not available for resident use in medication room refrigerator.
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 37
PPD vial expiration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse incident, medication reviews, transfer notifications, fall investigations, bed rail use, and expired medication storage. |
| Licensed Practical Nurse 3 | LPN | Witnessed resident fall and provided care. |
| Quality Improvement Registered Nurse | QIRN | Interviewed regarding medication reviews, transfer notices, and bed rail use. |
| Licensed Practical Nurse 4 | LPN | Observed expired PPD vial in medication room refrigerator. |
| Registered Nurse 1 | RN | Described transfer process and communication with families. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 5, 2019
Visit Reason
The inspection was conducted to assess compliance with admission order requirements, specifically to verify that physician orders for the use and care of a urinary foley catheter were obtained upon admission for Resident Identifier #222.
Findings
The facility failed to ensure an order for the use and care of a urinary foley catheter was obtained for Resident Identifier #222 upon admission on 8/28/2019. Interviews with nursing staff and the medical director confirmed the absence of the required order, though the resident had a foley catheter due to diagnoses including Neurogenic Bladder and paraplegia.
Deficiencies (1)
Failure to obtain physician orders for the use and care of a urinary foley catheter upon admission for Resident Identifier #222.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Registered Nurse | Admitting nurse for Resident Identifier #222 who forgot to write the urinary foley catheter order |
| Employee Identifier #2 | Director of Nursing / Registered Nurse | Responsible for ensuring physician orders for foley catheter use and care on admission |
| Employee Identifier #3 | Medical Director / Physician | Confirmed that an order should have been obtained for Resident Identifier #222 on admission |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 5, 2019
Visit Reason
The inspection was conducted to assess compliance with admission order requirements, specifically to verify that physician orders for the use and care of a urinary foley catheter were obtained upon admission for Resident Identifier #222.
Findings
The facility failed to ensure that an order for the use and care of a urinary foley catheter was obtained for Resident #222 upon admission on 8/28/2019. Interviews with nursing staff and the medical director confirmed the absence of the required order, though no harm was identified as the resident needed the catheter upon admission.
Deficiencies (1)
Failure to obtain physician orders for the use and care of a urinary foley catheter for Resident #222 upon admission.
Report Facts
Residents affected: 2
Date of admission: Aug 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Registered Nurse | Admitting nurse for Resident #222 who forgot to write the urinary foley catheter order. |
| Employee Identifier #2 | Director of Nursing / Registered Nurse | Responsible for ensuring orders were obtained for foley catheter use and care. |
| Employee Identifier #3 | Medical Director / Physician | Confirmed that an order should have been obtained for the foley catheter upon admission. |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 2, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, care planning, food safety, infection control, and medication administration at Mitchell-Hollingsworth Nursing & Rehabilitation.
Findings
The facility was found deficient in maintaining resident privacy by leaving a medication administration record screen unlocked, failing to revise a resident's smoking care plan accurately, improper food handling and sanitation practices, and inadequate infection control during eye drop medication administration. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (5)
Failed to ensure the MAR screen for Resident Identifier #93 was not left up/unlocked and open for public view, exposing personal and medical information.
Failed to revise the care plan for Resident Identifier #76 to accurately reflect smoking supervision status, resulting in unsupervised smoking contrary to the care plan.
Failed to prevent potential cross-contamination in food service, including improper glove use and hand hygiene, placing soiled pot holders on clean dishes, failure to maintain freezer temperature for ice cream, and incomplete monitoring of cold food temperatures.
Failed to ensure correct manual dishwashing procedures were followed regarding water temperature and chemical concentration.
Failed to ensure a licensed nurse wore clean gloves from appropriate sources prior to administering eye drop medication, instead using gloves from the uniform pocket, risking contamination.
Report Facts
Residents sampled for smoking: 3
Residents affected by smoking care plan deficiency: 1
Residents sampled for medication administration record review: 22
Residents affected by MAR screen privacy deficiency: 1
Opportunities for manual dishwashing chemical concentration monitoring: 93
Days with missing milk temperature documentation: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #7 | Registered Nurse, Director of Nursing | Named in MAR screen left unlocked deficiency |
| EI #1 | Licensed Practical Nurse | Named in MAR screen left unlocked deficiency and eye drop medication glove use deficiency |
| EI #3 | Restorative Registered Nurse | Interviewed regarding smoking care plan deficiency |
| EI #6 | Food Service Worker | Observed and interviewed regarding food service glove use and cross-contamination |
| EI #5 | Cook | Observed regarding glove use and food handling deficiencies |
| EI #4 | Certified Dietary Manager | Reported on temperature monitoring deficiencies |
| EI #2 | Registered Nurse, Infection Control | Interviewed regarding eye drop medication glove use deficiency |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 2, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, care planning, food safety, infection control, and medication administration practices at Mitchell-Hollingsworth Nursing & Rehabilitation.
Findings
The facility was found deficient in maintaining resident privacy by leaving medication administration records (MAR) screens unlocked, failing to revise a resident's smoking care plan accurately, improper food handling and sanitation practices in the dietary department, and improper glove use during eye drop medication administration. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (4)
Failed to ensure the MAR screen for Resident Identifier (RI) #93 was not left up/unlocked and open for public view, exposing personal and medical information.
Failed to revise the care plan for Resident Identifier (RI) #76 to accurately reflect smoking supervision status, despite resident smoking unsupervised contrary to the care plan.
Failed to prevent potential cross-contamination in food service including improper hand hygiene and glove use, placing soiled pot holders on clean dishes, failure to maintain freezer temperature for ice cream, and incomplete monitoring of cold food temperatures.
Failed to ensure a licensed nurse wore clean gloves properly during administration of eye drop medication, specifically by using gloves taken from the right pocket of the uniform top, risking contamination.
Report Facts
Residents sampled for smoking: 3
Residents affected by smoking care plan deficiency: 1
Residents sampled for MAR screen privacy: 22
Residents affected by MAR screen privacy deficiency: 1
Opportunities for monitoring cold food temperatures: 21
Omissions in monitoring cold food temperatures: 11
Manual dishwashing opportunities: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #7 | Registered Nurse (RN), Director of Nursing (DON) | Named in MAR screen privacy deficiency for leaving screen unlocked |
| EI #1 | Licensed Practical Nurse (LPN) | Named in MAR screen privacy deficiency for leaving screen unlocked and in eye drop medication glove use deficiency |
| EI #3 | Restorative Registered Nurse | Interviewed regarding smoking care plan deficiency |
| EI #6 | Food Service Worker | Observed and interviewed regarding food handling and glove use deficiencies |
| EI #5 | Cook | Observed and interviewed regarding food handling and glove use deficiencies |
| EI #4 | Certified Dietary Manager | Reported on temperature monitoring omissions and chemical test failures |
| EI #2 | Registered Nurse, Infection Control | Interviewed regarding proper glove use during eye drop medication administration |
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