| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 010007 | (X3) Date Survey Completed 12/12/2024 |
| Name of Provider or Supplier Mizell Memorial Hospital | Street Address, City, State 702 N Main St, Opp, 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) |
| K0372 | Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This STANDARD is not met as evidenced by: . Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, 8.5.6.3, and 8.5.4.4 This deficiency affects 2 of 3 smoke barriers. Findings include: During a tour of the facility, the surveyor observed the following: 1. On the 2nd floor, an unsealed 1/2" conduit being used as a cable chase for a gray cable above the ceiling over the cross-corridor doors (at room 230) of the smoke barrier between the Specialty Clinic Nursing Station and the Geri-psych Unit. 2. On the 3rd floor, an unsealed penetration of a 2" copper pipe above the ceiling over the cross-corridor doors (at the stairwell) of the smoke barrier between the ICU and MedSurg Units. A member of the maintenance staff was present when this deficiency was identified. . |