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 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)
K0761 Maintenance, Inspection & Testing - Doors

Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)


This STANDARD is not met as evidenced by:
. Based on the review of documentation and interview, the facility failed to maintain the required fire doors in the two hour fire rated barrier separating the three story construction type II (222) from the one story construction type II (000) (not allowed in a three story building) per the requirements of: 2012 NFPA 101, 19.7.6, and 8.3.3.1 2010 NFPA 80, 5.2, and 5.2.3 This deficiency affects the Kitchen and Dining Room areas. Findings include: During a tour of the facility, the facility failed to provide documentation of its annual fire door inspection and testing within the past 12 months for the kitchen roll down fire assembly doors located in the two hour fire rated barrier separating the Kitchen from the Dining Room at the following locations: 1. At the dish collection window 2. In front of the Victory Warmer equipment A member of the maintenance staff was present when this deficiency was identified. .