Mitchell-hollingsworth Nursing & Rehabilitation
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
hallucinations, delusions, and wanders one to three days out of the seven days look back period.Review of Resident R220's Care Plan, dated [DATE REDACTED], located in the EMR under the Care Plan tab, revealed Resident R220 is on Behavior Management Program monitored on Behavior Monitoring Record-Behaviors are wander into others' room and exit seek; rejection of care; physical behaviors directed towards others, and verbal behaviors. Interventions included .Approach in a calm manner and introduce yourself, Explain tasks and importance of care, Reassure resident that they are safe and we are here to help them, Validate feelings and redirect thoughts if possible/appropriate, Praise efforts and cooperation, Give choices if possible, Assess for basic needs (comfort, pain, hunger, thirst, toileting, needs, etc.), Make sure resident is safe and return later to attempt tasks as needed, remove from excess stimulation and provide 1:1 attention asneeded, walk with resident if wandering and redirect thoughts to a different subject; return to station/room, contact resident rep, resident services director, mental health, therapist, family, or sponsor as needed, contact physician for as needed (PRN) medication if above interventions are not successful.Review of the facility's Resident Abuse, Neglect, and Unusual Occurrence Report, Detailed Investigation, dated [DATE REDACTED], provided by the facility, revealed On [DATE REDACTED] at approximately 11am [Resident R220] and [Resident R137] were standing in the hallway when [Certified Nurse Aide (CNA) 5] heard [Resident R137] raise [his/her] voice which caused her to look around the corner from the nursing desk and witnessed [Resident R220] hit [Resident R137] in the face which resulted in [his/her] stumbling backwards into a resident's room without falling. CNA assisted [Resident R137] while [Resident R137] was holding [his/her] face oh it hurts. CNA noticed a red area above her lip. Resident Assistant who also responded to the residents walked with [Resident R220] and did not leave [his/her] side assisted with [Resident R137's] care. Intervention: Staff immediately intervened and removed both residents safely away from each other and attended to both simultaneously. [Resident R137] was assessed and treated with a cold pack on [his/her] lip, physician and family notified. [Resident R220] was assigned 1:1 care until [he/she] transferred to an acute care facility for continued assessment and treatment. [Resident R220] was admitted to the [Name] for further assessment and treatment. Based on findings from the statements, eyewitnesses, interviews and resident's history, it was concluded that there was a resident-to-resident altercation of Abuse-Physical between said residents. During an interview on [DATE REDACTED] at 2:48 PM, the Director of Nursing (DON) stated he recalled this incident, unsure what caused it, but resident had behaviors including wandering. DON added it was witnessed by the CNA. CNA5 and the Resident Assistant were unavailable for interview.
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If continuation sheet
F-Tag F0605
Federal health inspectors cited MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-09-18.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0628
Federal health inspectors cited MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-18.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0689
Federal health inspectors cited MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-09-18.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0700
Federal health inspectors cited MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL for a deficiency under regulatory tag F-F0700 during a standard health inspection conducted on 2025-09-18.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
F-Tag F0761
Federal health inspectors cited MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-18.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-05.
MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FLORENCE, AL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.