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 010001 (X3) Date Survey Completed 10/05/2017
Name of Provider or Supplier Southeast Health Medical Center Street Address, City, State 1108 Ross Clark Circle, Dothan, 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)
K0311 Vertical Openings - Enclosure
CFR(s): NFPA 101

Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.


This STANDARD is not met as evidenced by:
. DEVIN Based on observation and interview, the building failed to maintain the fire resistive rating of a stairwell per the requirements of: 2012 NFPA 101, 19.3.1.1 Findings include: On 10/02/2017, during a tour of the building from 10:30 am to 5:45 pm, SP/Stairwell #3 on the 6th Floor was observed with an unsealed penetration of a 4.5 inch sprinkler pipe into room 669. A member of the maintenance staff was present when this deficiency was identified. .