Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on May 12, 2026, at Step By Step Rosecrest, 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# 11677700
Component 01
Main Building
Based on a Medicaid Recertification Survey completed on May 12, 2026, it was determined that Step By Step Rosecrest, was not in compliance with the 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 Prompt
Plan of Correction:
NFPA 101 STANDARD
General Requirements - Other
Name - MAIN BUILDING 01 Component - 01
General Requirements - Other
2012 EXISTING
List in the REMARKS section any LSC Section 33.1 or 33.2 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishing equipment in one instance, affecting the entire facility
Findings include:
1. Observation on May 12, 2026, at 8:45 a.m., revealed the facility lacked documentation for monthly inspections of the fire extinguishers.
Interview with the House Manager and Staff on May 12, 2026, at 8:45 a.m., confirmed the fire extinguisher deficiencies.
Plan of Correction:The Director of Residential Services will retrain QIDP, Program Manager and DSSL on maintaining monthly inspections of fire extinguishers at the facility.
The QIDP, Program Manager or DSSL will provide the Director of Residential Services with fire extinguisher inspection documentation monthly, for 3 months, for review.
NFPA 101 STANDARD
Fire Alarm System - Testing and Maintenance
Name - MAIN BUILDING 01 Component - 01
Fire Alarm System - Testing and Maintenance
2012 EXISTING (Prompt)
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in two instances, affecting the entire facility.
Findings Include:
1. Review of documentation on May 12, 2026, at 8:30 a.m., revealed the facility lacked documentation for the following:
a) 8:30 a.m., the facility lacked documentation for the annual fire alarm inspection;
b) 8:35 a.m., the facility lacked documentation for the biennial smoke detector sensitivity test.
Interview with the House Manager and Staff on May 12, 2025, at 8:35 a.m., confirmed the facility lacked documentation for the annual and biennial fire alarm inspections.
Plan of Correction:The facility will maintain the fire alarm system.
The Director of Residential Services will obtain annual fire alarm inspection from December 2025. (Target Date: 5/12/2026) This documentation will be maintained in the fire safety binder, at the facility.
The Director of Residential Services will schedule the next available biennial smoke detector sensitivity test with Grunau Fire Protection. (Target Date: 8/12/2026) The documentation will be maintained in the fire safety binder, at the facility.
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 document review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility.
Findings include:
1. Observation on May 12, 2026, at 9:15 a.m., revealed the automatic sprinkler gauge in the basement closet was dated 2019, and the facility could not provide documentation that the gauge had been changed or recalibrated within the last five years.
2. Document review on May 12, 2026, at 9:17 a.m., revealed the facility lacked documentation verifying a five-year internal sprinkler pipe inspection was performed.
Interview with House Manager and Staff on May 12, 2026, at 9:17 a.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:The facility will maintain the automatic sprinkler system.
The Director of Residential Services will schedule the next available gauge change or recalibration appointment with Grunau Fire Protection, to maintain the automatic sprinkler gauge. (Target Date: 8/12/2026) The documentation will be maintained in the fire safety book, at the facility.
The Director of Residential Services will obtain paperwork from Grunau Fire Protection verifying a five year internal sprinkler pipe inspection from April 2024. (Target Date: 5/12/2026.) The documentation will be maintained in the fire safety book, at the facility.
NFPA 101 STANDARD
Utilities - Gas and Electric
Name - MAIN BUILDING 01 Component - 01
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NPFA 70, National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
Observations:
Based on documentation review and interview, it was determined the facility failed to maintain the following electrical devices in accordance with NFPA 101 (2012 ed.) in one instance, affecting the entire facility.
Findings include:
1. Documentation review on May 12, 2026, at 8:00 a.m., revealed the facility failed to perform an annual electrical outlet inspection.
Interview with the House Manager and Staff on May 12, 2026, at 8:00 a.m., confirmed the documentation listed above was not present at the time of survey.
Plan of Correction:The facility will maintain the electrical devices, in the facility, in accordance with NFPA 101 (2012 ed.).
The Director of Residential Services will retrain QIDP and Program Manager on annual electrical outlet inspections. (Target Date: 6/1/2026).
The Director of Residential Services will perform an annual electrical outlet inspection. (Target Date: 6/12/2026). The documentation will be maintained in the fire safety book, at the facility.
NFPA 101 STANDARD
Maintenance, Inspection and Testing - Doors
Name - MAIN BUILDING 01 Component - 01
Maintenance, Inspection & Testing - Doors
Door assemblies where the door leaf is required to swing in the direction of egress travel are inspected and tested annually per 7.2.1.15.
Fire door assemblies are inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Smoke door assemblies are inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
Door assemblies are visually inspected on both sides and the requirements under 7.2.1.15.7 are verified.
Individuals performing the door inspection and testing have an understanding of the operating components of the doors.
Written records of inspection and testing are maintained and are available for review.
33.7.7, 7.2.1.15 (LSC)
5.2. 5.2.3 (NFPA 80)
5.2.1 (NFPA 105)
Observations:
Based on documentation review and interview, it was determined the facility failed to perform the required annual fire door assembly inspection, affecting the entire facility.
Findings include:
1. Review of documentation on May 12, 2026, at 9:00 a.m., revealed the facility lacked documentation for an annual fire door assembly inspection.
Interview with the House manager and Staff on May 12, 2026, at 9:00 a.m. confirmed the annual fire door assembly inspection documentation was not available at the time of the survey.
Plan of Correction:The facility will maintain annual fire door assembly inspection, affecting the entire facility.
The Director of Residential Services will retrain the QIDP and Program Manager on scheduling and maintaining documentation of annual fire door assembly inspections.(Target Date: 6/1/2026).
The Director of Residential Services will schedule the next available fire door assembly inspection for the facility.(Target Date: 8/12/2026). The documentation will be maintained in the fire safety book, at the facility.
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