Surveys conducted by the Alabama Department of Public Health have left three of the seven speciality care assisted living facilities in Mobile with their licenses on a probationary status.

As a result, Arbors Specialty Care at Somerby of West Mobile, Gordon Oaks Memory Care Community and Elmcroft of Heritage Woods will have a few months to get back in compliance or face their licenses being permanently revoked.

“A probational license is usually issued in response to a bad [inspection]. It’s a downgrade from a regular license,” Dr. Walter Geary, director of health bureau standards for ADPH, said. “A probational license may only be granted for a maximum of one calendar year, which means a team will be back within the year to do a follow-up survey.”

All three of the locations listed above are licensed as Speciality Care Assisted Living Facilities (SCALFs), which are supposed to have trained staff and specific architectural features to better care for residents with cognitive impairments like Alzheimer’s.

However, ADPH found “unmet training requirements” in addition to a number of deficiencies ranging from simple reporting errors to others causing “actual harm.”

At Arbors, surveyors noted some caregivers were not always attentive to residents with walkers by not “watching and guiding” them around obstacles in the facility. One resident reported 13 falls or incidents that resulted in injury over a 16-month period, many of which surveyors wrote, “could have been avoided with proper supervision, staff intervention and training.”

Another Arbors resident became “so anxious and emotionally upset” the day after their spouse’s funeral they broke a window and then “used blood from an injured thumb to write the word ‘Help’ on the window.” A surveyor later noted it had been nearly a day since the resident was given anti-anxiety medication physicians had instructed the staff to administer every 12 hours.

Elmcroft had the fewest reported deficiencies, though ADPH still found that nurses there had failed to perform comprehensive assessments when residents were first admitted to the facility, and in some cases after significant changes in their health.

A surveyor also observed the nursing staff wasn’t sufficient enough to “meet the safety and care needs” of Elmcroft’s residents at all times. However, according to Geary, the number of reported deficiencies isn’t as important as the nature of those deficiencies.

“It all depends on professional judgment,” Geary said. “A facility could have 15 deficiencies related to paper records and we might not put them on probation, but another could have one major issue that leads to an immediate suspension of their license.”

That happened in 2013 when the Citronelle Assisted Living Facility was shut down after a resident walked out of the facility and struck his head on a curb. According to Geary, staff members were on “a smoke break” at the time didn’t notice anything until police responded to 911 calls from drivers that had noticed the resident lying by the roadway.

“So, yes, we closed them down because that put everyone at that facility’s life at risk,” he added.

That facility was purchased by new ownership later that year and a new license was obtained for the facility now known as Assisted Living of Citronelle. Ownership for that facility says they are in the good graces of state regulators and have no problems similar to the previous ownership.

Of the local facilities facing a probationary status this year, Gordon Oaks produced the most deficiencies by far, though it also has more residents than all the others combined. According to ADPH surveyors, “deficient practices” at Gordon Oaks resulted in “actual harm” to one resident and potential harm for 25 others over the past year.

In April, an “outbreak of nausea, vomiting and diarrhea” spread to 10 residents, 10 employees and resulted in at least one resident being transported to the hospital. Yet, despite being required to report outbreaks to public health officials, ADPH wasn’t informed for 25 days.

Another incident cited in the report dealt with a resident the Gordon Oaks staff found unresponsive in an activity room. Instead of receiving CPR immediately, [the resident] was taken to a room “16 doors away and placed on a bed before possibly-life-saving CPR” was initiated.

“While we can’t say anything the facility did directly resulted in the resident’s death, we can say they did not follow the standards of care,” Geary added. “If you find someone unresponsive, you’re supposed to immediately get them on a hard surface and start CPR.”

Another surveyor found three members of the overnight staff sleeping in an empty room, which left at least 29 residents with known cognitive impairments “neglected and unsupervised for unknown periods of time.”

The report claims that put all the residents “at significant risk for harm and even death,” and left a number of residents neglected, such as the two residents who “slept in their clothes and shoes because caregivers had not assisted [them].”

While Geary said some of the deficiencies were certainly “not good,” he added that facilities with a probational license have a chance to address their deficiencies. Most facilities in that position, Geary said, hire consultants to help get them in compliance with state health regulations.

That seems to be what Gordon Oaks has already done. When Lagniappe contacted administrator Linda Tiffany about this report, her only comment was to say, “We’ve hired a consulting company,” and “I hope you’re not putting this in the newspaper.”

The ADPH lists Jessica Keith as the administrator of Arbors Specialty Care and Joel Burdette as Elmcroft’s administrator — neither of whom returned calls seeking input on this report. At this point it’s unclear what corrective actions those facilities have taken.

The surveys from all three SCALFs are available at, though if the facilities address those deficiencies their licenses return to a regular status. If there are future violations at these facilities — even those that wouldn’t normally trigger probation — Geary said ADPH would immediately take steps to permanently revoke their licenses.

“Everybody knows a [license holder] gets one shot at a probational license, and if surveyors go in after eight months and everything’s fine, they’ll go back to a regular status,” Geary said. “But, if they come back two years later and it’s terrible — even if it doesn’t merit an immediate suspension — we go directly for license revocation. We won’t give them the opportunity to put people at risk.”

Editor’s note: This article was modified Dec. 14 to clarify that Citronelle Assisted Living Facility is now owned by another company and has a new name, Assisted Living of Citronelle. The current ownership says it has faced no sanctions from state regulators.