Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HENDRIX HEALTH AND REHABILITATION
DOUBLE SPRINGS, AL · 110 certified beds · Last Life Safety survey September 7, 2023
CMS Certification Number 015138 · first certified October 1979
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AL
13 citations — more than 73% of the 224 certified nursing homes in AL. Compared within AL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (September 2024 to February 2025), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was September 2023. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. AL has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
2 of the 13 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in AL, and nationally. Surveyors differ markedly between states, so the AL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in AL | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 12, 2018 | 5 |
| October 29, 2019 | 2 |
| September 7, 2023 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2023-09-07 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-09-07 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2023-09-07 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2023-09-07 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-09-07 |
| K-0281 | Install proper backup exit lighting. | 1 | 2018-09-12 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2018-09-12 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2018-09-12 |
What the citations cover
- Smoke Deficiencies 5
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 7, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (October 18, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 18, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 18, 2023) |
October 29, 2019 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 21, 2019) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 21, 2019) |
September 12, 2018 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 23, 2018) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 23, 2018) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 23, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 23, 2018) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 23, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.