Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

SELF SKILLED NURSING & REHAB

HUEYTOWN, AL · 131 certified beds · Last Life Safety survey March 18, 2021

CMS Certification Number 015212 · first certified January 1978

Ownership

Operated by TRAYLOR PORTER HEALTHCARE · For profit - Corporation

Ownership changed July 1, 2021 (change of ownership)from SELF HEALTH CARE AND REHAB CENTER INC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within AL

16 citations — more than 88% 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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 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 (March 2022 to August 2022), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was March 2021. 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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1 inspection-and-testing tag has 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

1 of the 16 citations on file is 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

E-0004

Physical environment (health survey)

5 physical-environment citations 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 16 Life Safety citations above. The Physical Environment Index

F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in AL, and nationally. Surveyors differ markedly between states, so the AL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	16
Median facility in AL	9
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
March 8, 2018	2
February 7, 2019	8
March 18, 2021	6

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0363	Install corridor and hallway doors that block smoke.	2	2021-03-18
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	2	2019-02-07
K-0351	Install an approved automatic sprinkler system.	1	2021-03-18
K-0753	Have restrictions on the use of highly flammable decorations.	1	2021-03-18
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	1	2019-02-07
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	1	2021-03-18
K-0361	Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.	1	2019-02-07
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2019-02-07

What the citations cover

Citations by CMS category

Smoke Deficiencies 10
Miscellaneous Deficiencies 3
Gas, Vacuum, and Electrical Systems Deficiencies 2
Emergency Preparedness Deficiencies 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	10
Miscellaneous Deficiencies	3
Gas, Vacuum, and Electrical Systems Deficiencies	2
Emergency Preparedness Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 18, 2021 — 6 citations

Citations issued on March 18, 2021
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (April 5, 2021)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 5, 2021)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (April 5, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (April 5, 2021)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 5, 2021)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (April 5, 2021)

February 7, 2019 — 8 citations

Citations issued on February 7, 2019
Tag	What the surveyor checks	Status
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (February 25, 2019)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 25, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 25, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 25, 2019)
K-0361	Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.	Deficient, Provider has date of correction (February 25, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 25, 2019)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (February 25, 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 (February 25, 2019)

March 8, 2018 — 2 citations

Citations issued on March 8, 2018
Tag	What the surveyor checks	Status
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (March 20, 2018)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 22, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.