Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 013429 (X3) Date Survey Completed 12/10/2025
Name of Provider or Supplier Grove Hill Primary Care Street Address, City, State 297 South Jackson Street, Grove Hill, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
J0041 PHYSICAL PLANT AND ENVIRONMENT

491.6(a) Construction: The clinic and the center is constructed, arranged, and maintained to insure access to and safety of patients, and provides adequate space for the provision of direct services.


This STANDARD is not met as evidenced by:
Based on observations and interview with staff, it was determined the clinic failed to ensure all electrical outlets had safety coverings in areas providing care to pediatric patients to ensure patient and staff safety. This had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy: None Provided A tour of the clinic was conducted on 12/9/2025 at 10:20 AM with Employee Identifier (EI) # 2, Office Manager, and the following was observed: Three electrical outlets in Exam room # 2 had no safety covers. Six electrical outlets in Exam room # 3 had no safety covers. During the tour, EI # 2 confirmed the clinic failed to ensure safety coverings were installed on all electrical outlets in areas providing care to pediatric patients to ensure patient and staff safety.