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 01C0001009 (X3) Date Survey Completed 06/05/2019
Name of Provider or Supplier Surgicare Of Mobile, Ltd Street Address, City, State 2890 Dauphin St, 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)
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 observation, review of documentation and interview, the facility failed to maintain the automatic sprinklers per requirements of:



2012 NFPA 101, 9.7.5

2011 NFPA 25, 5.3.1.1.1.6, and 5.3.1.1.1.3



Findings include:



On 06/06/2019, during a tour of the facility from 1:45 pm to 4:30 pm, the facility failed to provide the following documentation:

1. The dry sprinklers installed in 1993, located on front porch had been replaced or a representative sample tested within 10 years of installation

2. The 1993 fast-response sprinkler heads found in the original facility had been replaced or a representative sample tested within 20 years of installation.



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



.