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)
K0351 Sprinkler System - Installation
CFR(s): NFPA 101

Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)


This STANDARD is not met as evidenced by:
. ROLAND Based on observation and interview, the building failed to maintain the ceiling for the automatic sprinkler system per the requirements of: 2012 NFPA 101, 19.3.5.1 and 9.7.1.1 2010 NFPA 13, 8.5.4.2 2010 NFPA 13, 8.15.7.1 Findings include: On 10/03/2017, during a tour of the building from 8:00 am to 4:15 pm the following was observed: 1. A ceiling tile was found to have an approximately 2" hole in the following locations: a. Break Area b. Office Area MAC 2. The building failed to provide documentation that the canopy located next to stairwell 16 was flame retardant or provide sprinkler coverage for this canopy 3. No automatic sprinkler heads were observed in stairwell 2, that is located between the Doctor Office Building and the Medical Tower (Hospital) A member of the maintenance staff was present when this deficiency was found. .