Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on September 10, 2025, at Merakey Allegheny Valley School-Green Garden, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID # 27671100
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on September 10, 2025, it was determined that Merakey Allegheny Valley School Green Garden, was not in compliance with the following requirements of the Life Safety Code for an existing ICF/IID health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.470(j).
This is a one-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.
State plans approved as slow.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 Component - 01
Sprinkler System - Maintenance and Testing
2012 EXISTING (Prompt)
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, and NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies Up To and Including Four Stories in Height, are inspected, tested and maintained in accordance with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, are inspected, tested and maintained in accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section 13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20 years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at 10 years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25, section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system. __________________________________
(Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in one instance, affecting one of five bedrooms.
Findings include:
1. Observation on September 10, 2025, at 9:40 a.m., revealed there was a missing escutcheon plate for a sprinkler head on the ceiling of the closet in Bedroom 2.
Interview with the Facility Manager on September 10, 2025, at 11:30 a.m., confirmed the sprinkler system deficiency.
Plan of Correction:Allegheny Valley School Green Garden SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Green Garden SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Green Garden SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
On 9/10/25 maintenance order was written to have the escutcheon plate replaced on the sprinkler head on the ceiling of the closet in Bedroom 2. This repair was completed by a maintenance technician on 9/12/25. At this time, all other sprinkler heads in the home were checked by the technician as well to ensure that all escutcheon plates were in place and free of defect.
Ongoing monitoring of all sprinkler heads will be performed weekly by the Program Lead or designee and monthly by the Program Manager to ensure that all sprinkler heads have escutcheon plates in good condition. Any and all concerns will be reported to the Maintenance Department and Senior Director for appropriate follow-up.
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