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

LIGHTHOUSE REHABILITATION & HEALTHCARE CENTER

SELMA, AL · 68 certified beds · Last Life Safety survey January 24, 2020

CMS Certification Number 015413 · first certified January 1991

Ownership

Operated by BALL HEALTHCARE SERVICES · For profit - Corporation

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

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

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

The latest survey found 0 citations; the earlier surveys in the window averaged 8. 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 (February 2021 to June 2021), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was January 2020. 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

4 of the 16 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 16 Life Safety citations above. The Physical Environment Index

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
January 11, 2018	14
February 28, 2019	2
January 24, 2020	0

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-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	2	2019-02-28
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2018-01-11
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	1	2018-01-11
E-0007	Address patient/client population and determine types of services needed.	1	2018-01-11
E-0029	Develop a communication plan.	1	2018-01-11
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	1	2018-01-11
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	1	2018-01-11
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	1	2018-01-11

What the citations cover

Citations by CMS category

Smoke Deficiencies 7
Emergency Preparedness Deficiencies 4
Egress Deficiencies 2
Gas, Vacuum, and Electrical Systems Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	7
Emergency Preparedness Deficiencies	4
Egress 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 28, 2019 — 2 citations

Citations issued on February 28, 2019
Tag	What the surveyor checks	Status
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (April 8, 2019)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (April 8, 2019)

January 11, 2018 — 14 citations

Citations issued on January 11, 2018
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (February 15, 2018)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (February 15, 2018)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (February 15, 2018)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (February 15, 2018)
K-0226	Have horizontal exits used in accordance with safety requirements.	Deficient, Provider has date of correction (February 15, 2018)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (February 15, 2018)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (February 15, 2018)
K-0343	Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.	Deficient, Provider has date of correction (February 15, 2018)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 15, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 15, 2018)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 15, 2018)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (February 15, 2018)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (February 15, 2018)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (February 15, 2018)

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