Initial Comments:
Name - Component - --
Based on an Onsite Revisit to an Emergency Preparedness Survey completed on September 19, 2024, it was determined that Polk Center was in substantial compliance with the requirements of 42 CFR 483.475.
Plan of Correction:
Initial Comments:
Name - MAIN BUILDING 01 Component - 01
Facility ID # 16211100
Component 01
Meadowside Building
Based on an Onsite Revisit to a Medicaid Recertification Survey completed on September 19, 2024, it was determined that Polk Center 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 three-story, Type II (111), protected, non-combustible building, with a basement, that is partially sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Sprinkler System - Maintenance and Testing
Name - MAIN BUILDING 01 Component - 01
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
Observations:
Based on document review and interview, the facility failed to meet sprinkler system requirements for one of two components.
Findings include:
Document review on September 19, 2024, at 8:33 a.m., revealed the facility failed to provide documentation for the following sprinkler system requirements:
A. (8:33 a.m.) Last documented three-year, full-flow trip test occurred October 2020 by County Fire;
B. (8:33 a.m.) Facility lacked documentation for the annual partial trip test.
Interview with the safety manager on September 19, 2024, at 8:33 a.m., confirmed the deficiencies at the time of the survey.
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Based on an interview during an Onsite Revisit Survey conducted on February 13, 2025, at 12:35 p.m., it was determined that the facility had not completed items A and B.
Interview with the safety manager on February 13, 2025, at 12:35 p.m., confirmed the deficiencies were not corrected at the time of the Revisit Survey.
Plan of Correction:The FCOO in agreeance with ODP Bureau Director will Permanently Close the Woodside Building by writing a letter of intention to decertify all remaining beds located in the Woodside Building.
Initial Comments:
Name - BUILDING 05 Component - 05
Facility ID #16211100
Component 05
Woodside Building
Based on an Onsite Revisit to a Medicaid Recertification Survey completed on September 19, 2024, it was determined that Polk Center 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 three-story, Type II (222), fire resistive building, that is not sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Discharge from Exits
Name - BUILDING 05 Component - 05
Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7
Observations:
Based on observation and interview, the facility failed to meet exit discharge requirements.
Findings include:
Observation on September 19, 2024, at 10:46 a.m., revealed the first floor had an exit discharge near dining that was not a hard-packed, all-weather surface leading to a public way.
Interview with the safety manager on September 19, 2024, at 10:46 a.m., confirmed the exit discharge had not been maintained.
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Based on an interview during an Onsite Revisit Survey conducted on February 13, 2025, at 12:47 p.m., it was determined that the facility did not construct a hard-packed, all-weather surface that led to a public way for the exit discharge.
Interview with the safety manager on February 13, 2025, at 12:47 p.m., confirmed the deficiency was not corrected at the time of the Revisit Survey.
Plan of Correction:The FCOO in agreeance with ODP Bureau Director will Permanently Close the Woodside Building by writing a letter of intention to decertify all remaining beds located in the Woodside Building.
NFPA 101 STANDARD
Fire Alarm System - Installation
Name - BUILDING 05 Component - 05
Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8
Observations:
Based on observation and interview, the facility failed to meet fire alarm system installation requirements for one of two buildings.
Findings include:
Observation on September 19, 2024, at 10:20 a.m., revealed the Woodside exit stairways lacked smoke detectors.
Interview with the safety manager on September 19, 2024, at 10:20 a.m., confirmed the exit stairways lacked smoke detection.
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Based on an interview during an Onsite Revisit Survey conducted on February 13, 2025, at 12:54 p.m., it was determined that the facility failed to correct the smoke detection deficiency.
Interview with the safety manager on February 13, 2025, at 12:54 p.m., confirmed the smoke detection deficiency was not corrected at the time of the Revisit Survey.
Plan of Correction:The FCOO in agreeance with ODP Bureau Director will Permanently Close the Woodside Building by writing a letter of intention to decertify all remaining beds located in the Woodside Building.
NFPA 101 STANDARD
Corridor - Doors
Name - BUILDING 05 Component - 05
Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Based on observation and interview, the facility failed to meet corridor door requirements in one of two components.
Findings include:
Observation on September 19, 2024, at 11:30 a.m., revealed multiple Woodside corridor rooms had showers and bathrooms without doors to prevent the passage of smoke. Door hardware was visible, but curtains are currently being used.
Interview with the safety manager on September 19, 2024, at 11:30 a.m., confirmed the corridor rooms lacked doors to prevent the passage of smoke.
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Based on an interview during an Onsite Revisit Survey conducted on February 13, 2025, at 1:03 p.m., it was determined that the facility failed to correct the corridor door deficiency.
Interview with the safety manager on February 13, 2025, at 1:03 p.m., confirmed the corridor door deficiency was not corrected at the time of the Revisit Survey.
Plan of Correction:The FCOO in agreeance with ODP Bureau Director will Permanently Close the Woodside Building by writing a letter of intention to decertify all remaining beds located in the Woodside Building.
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