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 012509 (X3) Date Survey Completed 04/05/2023
Name of Provider or Supplier North Alabama Nephrology Center Street Address, City, State 1311 North Memorial Parkway #200, 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)
K0351 Sprinkler System - Installation
CFR(s): NFPA 101

Sprinkler System - Installation Sprinkler systems (if installed) are installed per NFPA 13. Where more than two sprinklers are installed in a single area for protection, waterflow devices shall be provided to sound the building fire alarm system or to notify a constantly attended location such as a PBX, security office, or emergency room. 20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2, 9.7.1.2, 9.7, NFPA 13


This STANDARD is not met as evidenced by:
. Based on review of documentation and observation, the facility failed to provide information on the automatic sprinkler anti-freeze system per the requirements of: 2012 NFPA 101, 21.1.6.1, Table 21.1.6.1 and 9.7.1.1 2010 NFPA 13.7.6.1.5, and TIA 10-2 This deficiency affects 1 of 1 anti-freeze systems. Findings include: On 04/05/2023, during a tour of the facility from 8:30 am to 10:30 am, the facility failed to provide the following documentation on the automatic sprinkler anti-freeze system: 1. The anti-freeze placard shall provide the following information: a. Manufacture type and brand b. Concentration by volume of anti-freeze used c. Volume of anti-freeze used in system 2. The facility failed to provide certificates/letter from the manufacturer on the pre-mixed solutions installed in the anti-freeze system. The certificates/letter shall include the following information: a. Type of anti-freeze b. Concentration by volume c. The freezing point A member of the maintenance staff was present when this deficiency was identified. .