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

ROANOKE REHABILITATION & HEALTHCARE CENTER

ROANOKE, AL · 65 certified beds · Last Life Safety survey September 20, 2023

CMS Certification Number 015424 · first certified July 1993

Ownership

Operated by BALL HEALTHCARE SERVICES · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

13
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

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

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

The latest survey found 10 citations; the earlier surveys in the window averaged 1.5. 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 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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Which alerts

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

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)

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 13 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

This facility13AL median9National median11
Citations on file over three years, compared
MeasureCitations
This facility13
Median facility in AL9
Median facility nationally11

Survey history

Citations at each Life Safety survey
22019-0512022-03102023-09
Citations at each Life Safety survey
Survey dateCitations
May 9, 20192
March 3, 20221
September 20, 202310

Most-cited tags

Most-cited tags at this facility
K-03512K-03532K-03721K-02321K-03461K-03541K-03451K-07121
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0351Install an approved automatic sprinkler system.22023-09-20
K-0353Inspect, test, and maintain automatic sprinkler systems.22023-09-20
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12022-03-03
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.12023-09-20
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.12023-09-20
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.12023-09-20
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12023-09-20
K-0712Have simulated fire drills held at unexpected times.12023-09-20

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Emergency Preparedness Deficiencies 2
  • Miscellaneous Deficiencies 1
  • Egress Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Emergency Preparedness Deficiencies2
Miscellaneous Deficiencies1
Egress Deficiencies1

Every citation on file

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

September 20, 2023 — 10 citations

Citations issued on September 20, 2023
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (November 1, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (November 1, 2023)
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (November 1, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (November 1, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (November 1, 2023)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (November 1, 2023)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (November 1, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 1, 2023)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (November 1, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (November 1, 2023)

March 3, 2022 — 1 citation

Citations issued on March 3, 2022
TagWhat the surveyor checksStatus
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (April 4, 2022)

May 9, 2019 — 2 citations

Citations issued on May 9, 2019
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (June 19, 2019)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 19, 2019)

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