Initial Comments:
Name - Component - --
Based on an Emergency Preparedness Survey completed on March 29, 2023, at Step by Step, Inc., Pringle, 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 # 08791100
Component 01
Building 01
Based on a Medicaid Recertification Survey completed on March 29, 2023, it was determined that Step By Step Inc., Pringle, 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 two-story, Type V (000), unprotected wood frame building, with a basement, that is fully sprinklered.
State plans approved as impractical.
Plan of Correction:
NFPA 101 STANDARD
Stairways and Smokeproof Enclosures
Name - MAIN BUILDING 01 Component - 01
Stairways and Smokeproof Enclosures
2012 EXISTING (Prompt)
Interior stairs used as a primary means of escape shall be enclosed with fire barriers in accordance with Section 8.3 having a minimum 1/2-hour fire resistance rating. Stairs shall comply with 7.2.2.5.3. The entire primary means of escape shall be arranged so that it is not necessary for the occupants to pass through a portion of a lower story unless that route is separated from all spaces on that story by construction having not less than a 1/2-hour fire resistance rating. In buildings of construction other than Type II (000), Type III (200), or Type V (000), the supporting construction shall be protected to afford the required fire resistance rating of the supported wall.
1. Stairs that connect a story at street level to only one other story shall be permitted to be open to the story that is not at street level.
2. In Prompt Evacuation Capability facilities, stair enclosures shall not be required in buildings of three or fewer stories protected throughout by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick response or residential sprinklers. This exception shall be permitted only if a primary means of escape from each sleeping area still exists that does not pass through a portion of a lower floor, unless that route is separated from all spaces on that floor by construction having a 1/2-hour fire resistance rating.
3. In Prompt Evacuation Capability facilities, stair enclosures shall not be required in buildings of two or fewer stories with not more than eight residents and are protected by an approved automatic sprinkler system in accordance with 33.2.3.5 that uses quick-response or residential sprinklers. The requirement found at section 33.2.2.3.3, 33.2.3.4.6 or 33.2.3.4.3.7 are not permitted to be used in this instance.
4. In Prompt Evacuation Capability facilities, of three or fewer stories protected by an approved automatic sprinkler system in accordance with 33.2.3.5, stairs shall be permitted to be open at the topmost story only. The entire primary means of escape of which the stairs are a part shall be separated from all portions of lower stories.
Stairs shall comply with 7.2.2 unless otherwise specified in Chapter 33. Winders complying with 7.2.2.2.4 shall be permitted. Exterior stairs shall be protected against blockage caused by fire within the building.
33.2.2.4, 33.2.2.6
Observations:
Based on observation and interview, it was determined the facility failed to maintain one exit stair, affecting one of two floors.
Findings include:
1. Observation on March 29, 2023, at 9:40 a.m., revealed the front stair tower door, accessing the kitchen area, required adjustment to fully latch.
Exit interview with the Program Director on March 29, 2023, at 10:10 a.m., confirmed the the exit stair deficiency.
Plan of Correction:S225: Stairways and Smokeproof Enclosures
The fire door inspector was at site on 3/29/2023 to complete adjustments to ensure front stair tower door, accessing the kitchen area was fully latched. Fire door was tested and fully latched and functional. Fire doors will continue to be inspected annually to ensure functioning.
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 documentation review, observation, and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting three of three floors.
Findings include:
1. Observation on March 29, 2023, between 9:44 a.m., and 9:49 a.m., revealed the following:
a. Several penetrations of the monolithic ceiling assembly, located within the basement area.
b. The facility lacked five year, internal valve and internal pipe testing data.
Exit interview with the Program Director on March 29, 2023, at 10:10 a.m., confirmed the automatic sprinkler system deficiencies.
Plan of Correction:S353: Sprinkler System - Maintenance and Testing
1a. Contractor is scheduled to come the week of 4/10/2023 to give bid for and schedule the monolithic ceiling assembly, located within the basement area. QIDP will ensure that work is completed.
K&K Fire Authority has been contacted to complete a 5-year internal valve and internal piping inspection of the fire sprinkler system. They are scheduled to come to the program on 4/11/2023. The QIDP will ensure the inspection is completed
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