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
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in one location, affecting one of one floor.
Findings include:
1. Observation on October 3, 2024, at 10:55 a.m., revealed the attic access panel/stair, located within the Clean Linen Room, failed to close, leaving an opening within the ceiling assembly.
Exit interview with the Facility Administrator on October 3, 2024, between 11:35 a.m., and 11:40 a.m., confirmed the automatic sprinkler system deficiency.
| | Plan of Correction - To be completed: 11/22/2024
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Sweden Valley Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Sweden Valley Manor credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident.
A: The b hall attic access panel/stair will be repaired to close completely by 10/18/2024 B: A whole house audit of all attic access points will be completed to ensure they all close properly by 10/18/2024 C: Education will be provided by NHA to ESS on NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water based Fire Protection System by 10/18/2024 D: An audit will be completed by ESS or designee on attic access points to ensure proper closure weekly x 4 weeks and monthly x 2 months. E: Results of the attic access point audits will be reported to the QAPI committee
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