Advanced Health Care of Colorado Springs

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was .. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101 1. Fire stopping systems needed for penetrations along co.. Based on observation and staff interviews during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Emergency light in generator enclosure are unabl.. Based on observation and staff interviews it was determined that the facility failed to maintain a fire-safe environment within the facility Life Safety Code, Section 19.7.81. Space heater in maintenance room.Life Safety Cod.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section 19.3.2.11. Dry storage fire door is chained to be held open. &.. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. NFPA 101 and NFPA 70. This was e.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 101(chapter 19, section 19.3.2.5.3),National Fire Protection Association (NFPA) Standard 96. 1. Mis.. Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101.1. Fire Alarm Out of Services paperwork not provided NFPA 101 9.6.1.6* Wher.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 251. Sprinkler Out of Service needs change to 10 hour.. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1. Therapy kitchen extinguisher exceeds 5ft in height.NFPA 10 6.1.3.8 Installation Height... Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. 1. Signs needed for "full" and "empty" for racked oxygen storage. NFPA 99 11.6.5.2 If empt.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Escutcheon plates t.. The Initial Comments (ID Tag K0000) are informational only and are a representation of the facility' s general characteristics.The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Fe..

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. Chalks in kitchen on stove wheels | Kitchen stove wheels do not have devices installed to return to same position after pulling out for cleaningNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations.NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location.This deficiency has the potential to affect occup.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101No Dry Valve full trip report available during inspectionSprinkler freezer/refrigerator corrosion | Sprinkler heads both freezer/fridge corroded Also unable to identify temperature of headNFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance directo.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code NFPA 101.Fire Drills not compliant | No Fire Drill 3rd shift (4th qrt)/2nd shift (2nd qrt)NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.NFPA 101, 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.This deficiency has the potentia.. The Initial Comments (ID Tag K0000) are informational only and are a representation of the facility' s general characteristics.The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70 (a).The building is a one story wood framed structure, Type V (111). The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The facility ' s fire sprinkler system is a wet and a dry system.This survey of the 34 bed facility was conducted on April 10, 2023 for compliance with the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies and Referenced Publications. The facility will meet these requirements with the correction of the deficiencies list.. Through documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:Written records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade for receptacles in patient care need to be updated to verify all areas accounted for. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms.6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.6.3.3.2.3 Correct polarity of the hot and neutral connections in ea..

A recertification survey was conducted 3/13/23-3/16/23. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 3/13/23 to 3/16/23. No deficiencies were cited. Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#7) of two residents reviewed for falls out of 18 sample residents.Specifically the facility failed to timely implement appropriate and effective interventions to prevent five falls in a two week period. Findings include: I. Facility policy The Fall Prevention policy, updated 9/28/22, was provided by the director of nursing (DON) on 3/15/23 at 4:30 p.m., read in part:"Safety interventions will be implemented and monitored with appropriate documentation as indicated ...Based upon the calculated score of the Fall Risk Assessment, the fall risk protocol and care plan will be completed and the appropriate interventions initiated. The admitting nurse/nurse manager will be responsible for insuring that interventions are initiated and communicated to appropriate staff for follow through ...The assigned licensed nurse will be responsible for ensuring .. Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable interventions and objectives for one (#12) of three out of 18 sample residents. Specifically, the facility failed to develop a person centered care plan for Resident #12' s mental illness that included interventions, behaviors, and non-pharmaceutical approaches. Findings include: I. Resident #12 A. Resident status Resident #12, age 74, was admitted to the facility on 2/8/23. According to the March 2023 computerized physician orders (CPO), diagnoses included bipolar II disorder and unspecified dementia without psychotic disturbance. The 2/11/22 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a score of ten out of 15. No behaviors were indicated. B. Record review The mood care plan, revised on 2/17/23 revealed the resident was taking an anticonvulsant for bipolar ..