Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MOUNDVILLE HEALTH AND REHABILITATION, LLC
MOUNDVILLE, AL · 68 certified beds · Last Life Safety survey October 7, 2021
CMS Certification Number 015187 · first certified October 1977
Ownership
Operated by NHS MANAGEMENT · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AL
9 citations — more than 46% 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 0 citations; the earlier surveys in the window averaged 4.5. 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 (October 2022 to March 2023), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was October 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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Emergency preparedness
1 of the 9 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
Physical environment (health survey)
2 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 9 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 | 9 |
| Median facility in AL | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 22, 2018 | 3 |
| April 4, 2019 | 6 |
| October 7, 2021 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2019-04-04 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2019-04-04 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2019-04-04 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2018-03-22 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2018-03-22 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2019-04-04 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2019-04-04 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2018-03-22 |
What the citations cover
- Smoke Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 2
- Emergency Preparedness Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 4, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (May 13, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 13, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 13, 2019) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 13, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 13, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 13, 2019) |
March 22, 2018 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 3, 2018) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 3, 2018) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 3, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.