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K0353
E

Failure to Maintain Sprinkler System and Provide Required Inspection Documentation

Lake City, Florida Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 requirements. During a record review with the Administrator and Maintenance Director, the facility was unable to provide documentation of the required 5-year internal backflow inspection report. Additionally, during a facility tour, surveyors observed that the fire backflow device located at the main entrance was 'Red Tagged,' indicating that the system was in failure and inoperable. These findings were confirmed by the Maintenance Director during the interview and acknowledged by both the Administrator and Maintenance Director at the exit conference. No information about residents or their medical conditions was included in the report.

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