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)
J0044 PHYSICAL PLANT AND ENVIRONMENT

The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(3) The premises are clean and orderly.


This STANDARD is not met as evidenced by:
Based on observation and interview, it was determined the clinic failed to ensure safe use of specialized suture scissors and forceps to prevent the potential spread of infectious diseases. This deficient practice had a potential to negatively affect all staff and patients served by the facility. Findings include: Policy: DISINFECTION AND STERILIZATION POLICY Policy number: 238.0 Date: 10/22/2020 Policy Purpose: The purposes of this policy are to clearly outline the procedures which shall be taken to disinfect and sterilize equipment, supplies, instruments, and surfaces. Policy Body: Disinfection and Sterilization... 3. Pretreating or Preparing Items for Sterilization a. Dirty items shall be transported to a designated dirty area within the clinic from the original patient care area. Care shall be taken to prevent contamination during transport... 8. Reusable DME and Supplies: ...supplies which may be reused by multiple patients shall be labeled as either clean or dirty to alert staff of the condition of the item. A tour of the medication and supply storage area was conducted on 12/9/2025 at 11:30 AM with Employee Identifier (EI) # 4, Medical Assistant. The following deficient practice was observed: Fifteen unpackaged suture scissors, three unpackaged forceps and one sealed package containing a suture scissor and forceps all stored in a plastic container together were observed on the countertop. An interview was conducted on 12/9/2025 at 11:35 with EI # 4, who confirmed the scissors and forceps in the sealed package were sterile and ready for patient use. She/he further confirmed the unpackaged scissors and forceps had been pre-cleaned and were ready to be sent to autoclave and were not labeled and stored per clinic policy to assure staff and patient safety.