Failure to Maintain Sprinkler System and Implement Required Notifications and Fire Watch
Summary
Surveyors identified a deficiency related to fire protection and life safety requirements under 59A-4.130 and NFPA 101. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility could not provide documentation that the fire riser and associated sprinkler system were maintained in proper working order. Three red tags from the sprinkler vendor were observed on the sprinkler system since 2025, indicating unresolved issues with the system’s status. The facility also failed to follow required procedures when the fire protection system was not fully functional. Specifically, the facility did not notify the authorities having jurisdiction, including the Agency for Health Care Administration and Palm Beach County Fire Rescue, as required when there is a system failure of the sprinkler system. In addition, the facility did not implement a fire watch during the period when the sprinkler system was not in proper working order. The Maintenance Director and the Administrator acknowledged these failures to notify the appropriate authorities and to initiate a fire watch. This deficiency had the potential to affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
The facility placed itself on a self imposed fire watch due to the red tags given to us from our sprinkler system vendor. The fire watch started on [R] and is still on-going pending the final report from our vendor. The facility notified the local area office of AHCA and the Fire Marshall of the Palm Beach Fire Rescue. The facility notified both parties on [R]. Daily logs are being sent to the AHCA surveyor and the fire Marshall. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Penalty
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