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 01C0001000 (X3) Date Survey Completed 11/14/2019
Name of Provider or Supplier Montgomery Surgical Center Llc Street Address, City, State 470 Taylor Road, Montgomery, 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)
K0321 Hazardous Areas - Enclosure
CFR(s): NFPA 101

Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7


This STANDARD is not met as evidenced by:
.



Based on observation and interview, the facility failed to maintain the hazardous rooms per the requirements of:



2012 NFPA 101, 21.3.2 and 39.3.2.1



This deficiency could affect approximately 20 occupants.



Findings include:



On 11/14/2019, during a tour of the facility from 8:00 am to 4:45 pm, the surveyor observed Post OP Room 14 being used as a General Storage Room withthout a self-closing device on the door.



A member of maintenance staff was present when this deficiency was identified.



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