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 010006 (X3) Date Survey Completed 07/15/2010
Name of Provider or Supplier North Alabama Medical Center Street Address, City, State 1701 Veterans Drive, Florence, 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)
K0056 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5


This STANDARD is not met as evidenced by:
Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed: A) Missing ceiling tiles in the Nitrous Oxide Room. NFPA 13 5-6., Sprinklers shall be arranged to be in compliance. B) Escutcheon plate missing on a sprinkler at the main entrance of the facility. 2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. 27382 The facility failed to maintain the sprinkler system per code. Findings include: C) During the survey, the following was observed: 1. Second Floor - Break Down Box Room in the O.R. - the attic access in the closet is falling out of the ceiling. 2. Third Floor - Old Heart Health now Storage - was missing ceiling tile. 1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.