| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001002 | (X3) Date Survey Completed 04/09/2025 |
| Name of Provider or Supplier Mobile-Sc, Ltd | Street Address, City, State 6144 A Airport Boulevard, Mobile, 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) |
| K0000 | K3 Building: 0101 K6 Plan Approval: 2004 K7 Survey Under: 2012 Existing AHCO Generator: Diesel, Caterpillar, 250 kW with remote stop station (installed 2011) FACP: Edwards: EST2 (installed 2004) Locking Devices: None Smoke Detection: Corridor Case per day: 50, ortho, eye surgery, and pain management Type of Structure: one story with a partial basement unprotected noncombustible, Type II (000). The facility has a complete automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 416.44(b) were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. . |
| K0131 | Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the 2-hour fire barrier separating the Ambulatory Surgery Center (ASC) from the Medical Office Building per the requirements of: 2012 NFPA 101, 21.1.3.1, and 6.1.14 This deficiency affects the only 2 hour fire barrier separating the different occupancies. Findings include: During a tour of the facility, the surveyor observed a 2” unsealed penetration over the Front Entrance double doors, above the Lobby ceiling in the 2-hour fire rated barrier separating the ASC from the Medical Office Building. A member of the maintenance staff was present when this deficiency was identified. . |
| K0211 | Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 21.2.1, and 7.2.1.9.1.3 This deficiency affects 1 of 3 powered doors. Findings include: During a tour of the facility, the surveyor observed the powered egress door leafs between the Operating Room Suite and the Pre-Operation Suite did not have signs on the egress sides that reads: "IN EMERGENCY, PUSH TO OPEN". A member of the maintenance staff was present when this deficiency was identified. . |
| K0351 | Sprinkler System - Installation CFR(s): NFPA 101 Sprinkler System - Installation Sprinkler systems (if installed) are installed per NFPA 13. Where more than two sprinklers are installed in a single area for protection, waterflow devices shall be provided to sound the building fire alarm system or to notify a constantly attended location such as a PBX, security office, or emergency room. 20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2, 9.7.1.2, 9.7, NFPA 13 This STANDARD is not met as evidenced by: Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects the complete sprinkler system. Findings include: During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following: (1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet (4) Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified. . |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on review of documentation, the facility failed to maintain the automatic sprinkler system per the requirements of: 2012 NFPA 101, 4.6.1.2, 4.6.12.3, 4.6.12.4, 4.6.12.5, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, 5.3.1.1.1.3 This deficiency affects the complete sprinkler system. Findings include: The facility failed to provide documentation that the 2004 quick-response sprinklers located throughout the facility had been replaced or a representative sample tested within 20 years of installation A member of the maintenance staff and the administrator were present when this deficiency was identified. . |
| K0372 | Subdivision of Building Spaces – Smoke Barrier Construction CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 21.3.7.5, 21.3.7.6, 8.5 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 21.3.7.5, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 of 1 smoke barriers. Findings include: During a tour of the facility, the surveyor observed a 1" unsealed penetration of multiple white cables above the ceiling, over the cross-corridor doors between the Operating Room Suite and the Pre-Operation Suite corridors on both sides of the smoke barrier. A member of the maintenance staff was present when this deficiency was identified. . |
| K0920 | Electrical Equipment – Power Cords and Extension Cords CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This STANDARD is not met as evidenced by: Based on observation, the facility failed to maintain the electrical equipment per the requirements of: 2012 NFPA 99, 10.2.3.6, and 10.2.4 2011 NFPA 70, 400.8 S&C: 14-46-LCS This deficiency affects the Lobby. Findings include: During a tour of the facility, the surveyor observed two table lamps plugged into a brown extension cord under the table, near the Front Entrance in the Lobby. A member of the maintenance staff was present when this deficiency was identified. |