| 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) |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 9.7.5, 9.7.7, and 9.7.8 2011 NFPA 25, 5.3.1.1.1.3 and 5.3.1.2 This deficiency affects the complete facility sprinkler system. Findings include: During a tour of the facility, the facility failed to provide documentation that the 2007 quick response, dry sprinklers located in the walk-in cooler and freezer had been replaced or a representative sample tested within 10 years of installation. A member of the maintenance staff was present when this deficiency was identified. . |