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 01C0001013 (X3) Date Survey Completed 06/11/2025
Name of Provider or Supplier Op Surg Ctr, Inc And Surgicare Of Huntsville, Inc Street Address, City, State 721 Madison Street, Huntsville, 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)
K0321 Hazardous Areas - Enclosure
CFR(s): NFPA 101

Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7


This STANDARD is not met as evidenced by:
Based on observation, the facility failed to maintain a hazardous room per the requirements of:

 

2012 NFPA 101, 21.3.2, 39.3.2.1 and 8.7

 

This deficiency affects 1 hazardous room.


Findings include:

 

During a tour of the facility, the surveyor observed an unsealed penetration through the ceiling of the South Riser Room of a 4" PVC conduit used as an exhaust for 3 gas, tankless water heaters.

 

A member of maintenance staff was present when this deficiency was identified.

 

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