Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ASPIRE PHYSICAL RECOVERY CENTER AT CAHABA RIVER
VESTAVIA, AL · 120 certified beds · Last Life Safety survey January 12, 2024
CMS Certification Number 015468 · first certified September 2016
Ownership
Operated by NHS MANAGEMENT · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
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 3 citations; the earlier surveys in the window averaged 5.5. 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 (January 2025 to June 2025), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was January 2024. 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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4 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.
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 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 |
|---|---|
| August 16, 2018 | 6 |
| September 19, 2019 | 5 |
| January 12, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-01-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-01-12 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2019-09-19 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-01-12 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2018-08-16 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2018-08-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2019-09-19 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2019-09-19 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 12, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 2, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 31, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 2, 2024) |
September 19, 2019 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 28, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 28, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 28, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 28, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 28, 2019) |
August 16, 2018 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 25, 2018) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 25, 2018) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 25, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 25, 2018) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 25, 2018) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 25, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.