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Complaint Investigation

Mitchell-hollingsworth Nursing & Rehabilitation

September 18, 2025 · Florence, AL · 805 Flagg Circle
Citations 6
CMS Rating 3/5
Beds 222
Provider ID 015031
Healthcare Facility
Mitchell-hollingsworth Nursing & Rehabilitation
Florence, AL  ·  View full profile →
Inspection Summary

MITCHELL-HOLLINGSWORTH NURSING & REHABILITATION in FLORENCE, AL — inspection on September 18, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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] 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.

Facility ID:

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.

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.

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.

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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.

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.

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.


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