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 11/14/2023
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)
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 provide an electronic supervising (tamper switch) for the backflow preventer valve for the automatic sprinkler system per the requirements of:





2012 NFPA 101, 21.3.5.1, and 9.7.2.1


2010 NFPA 72, 10.7.4, and 10.16.2





This deficiency affects the entire sprinkler system.





Findings include:





During a tour of the facility, the surveyor observed the backflow preventer valve for the automatic sprinkler system did not have an electronic supervising device (tamper switch) installed.





A member of the maintenance staff and the administrator were present, when this deficiency was identified.





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