Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FAIRHOPE HEALTH & REHAB
FAIRHOPE, AL · 131 certified beds · Last Life Safety survey February 25, 2022
CMS Certification Number 015222 · first certified March 1981
Ownership
Operated by NOLAND HEALTH · Non profit - Corporation
- Ownership changed November 1, 2017 (change of ownership)to FAIRHOPE HEALTH AND REHAB from FAIRHOPE HEALTH & REHAB, LLC
Position within AL
14 citations — more than 79% 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 2 citations; the earlier surveys in the window averaged 6. 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 (March 2023 to July 2023), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was February 2022. 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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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 14 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 14 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 | 14 |
| Median facility in AL | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 25, 2018 | 5 |
| May 23, 2019 | 7 |
| February 25, 2022 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2022-02-25 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2022-02-25 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2018-05-25 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2019-05-23 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 1 | 2018-05-25 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2019-05-23 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2019-05-23 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2019-05-23 |
What the citations cover
- Smoke Deficiencies 6
- Services Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Services Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 25, 2022 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 6, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 6, 2022) |
May 23, 2019 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 4, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 4, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 4, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 4, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (July 4, 2019) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 4, 2019) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 4, 2019) |
May 25, 2018 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 28, 2018) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 28, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 28, 2018) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 28, 2018) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 28, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.