Cantril House Assisted Living

A relicensure survey was completed on 12/9/25. A deficiency was cited. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 13 current residents. Findings include: On 12/9/25 at approximately 8:00 a.m., the Involuntary Discharge Grievance Policy was requested; however, the residence was unable to provide an Involuntary Discharge Grievance Policy that included the required elements of Chapter 7 Regulation 9.3 (A-I).On 12/9/25 at 3:00 p.m., the administrator stated she was aware of the current state regulation; however, she believed their existing discharge and grievance policies were sufficient, and did not need to create a new policy.

A relicensure revisit was completed on 5/19/25 for the previous deficiencies cited on 12/7/22. The residence is in compliance with all regulations surveyed.The deficiencies cited for Event PNDS12 were cited prior to the regulation revision that was implemented on 3/17/25. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Based on observation and staff interviews, it was determined that the facility failed to maintain fire barriers and fire doors in accordance with NFPA 101 Chapter 33,8 and 7. The second-floor east stairwell is locked in the path of egress. The gate at the bottom of the stairs does not free egress. Revisited on 2/21/2025 citation not corrected.33.3.2.2.2 Doors.Doors in means of egress shall be as follows:(1) Doors complying with 7.2.1 shall be permitted.(2) Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding.(3) No door in any means of egress, other than those meeting the requirement of 33.3.2.2.2(4) or (5), shall be locked against egress when the building is occupied.(4) Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.(5) Access-controlled egress doors in accordance with 7.2.1.6.2 shall be permitted.(6) Revolving doors complying with 7.2.1.10 shall be permitted.7.2.1.1.2 Every door opening and every principal entrance that is required to serve as an exit shall be designed and constructed so that the path of egress travel is obvious and direct. Windows that, because of their physical configuration or design and the materials used in their construction, have the potential to be mistaken for door openings shall be made inaccessible to the occupants by barriers or railings.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference. Revisit of 12/16/2024 complaint survey was completed on 02/21/2025. One deficiency was recited.

A survey prompted by CO#38683 was completed on 12/16/2024. Two deficiencies were cited.The initial comments (ID Prefix Tag #P000) are informational only and represent the facility' s general characteristics. The facility shall maintain and not diminish the existing life safety features that met the requirements during licensure or certification.This facility has a license for 16 beds. The facility is a two-story, Type V (000) with a complete 13-R fire sprinkler system. This survey, conducted December 16, 2024, inspected for compliance with the fire safety requirements for a small residential board and care facility using the 2003 edition of National Fire Protection Association (NFPA) 101 Life Safety Code®, Chapter 33, entitled, "Existing Residential Board and Care Occupancies," as well as the 2010 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety. Based on observation and staff interviews, it was determined that the facility failed to maintain fire barriers and fire doors in accordance with NFPA 101 Chapter 33,8 and 7. The second-floor east stairwell is locked in the path of egress. The gate at the bottom of the stairs does not free egress.33.3.2.2.2 Doors.Doors in means of egress shall be as follows:(1) Doors complying with 7.2.1 shall be permitted.(2) Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding.(3) No door in any means of egress, other than those meeting the requirement of 33.3.2.2.2(4) or (5), shall be locked against egress when the building is occupied.(4) Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.(5) Access-controlled egress doors in accordance with 7.2.1.6.2 shall be permitted.(6) Revolving doors complying with 7.2.1.10 shall be permitted.7.2.1.1.2 Every door opening and every principal entrance that is required to serve as an exit shall be designed and constructed so that the path of egress travel is obvious and direct. Windows that, because of their physical configuration or design and the materials used in their construction, have the potential to be mistaken for door openings shall be made inaccessible to the occupants by barriers or railings.This deficiency has the potential to affect occupants, who might include residents, staff, and visit.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, 72, and 13.A new fire alarm panel was installed without plansFire sprinkler redesigns without an approved permit.33.3.3.4.6.2 Where a new fire alarm system is installed, or the existing fire alarm system is replaced, emergency forces notification shall be provided in accordance with 9.6.4.9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.33.3.3.5.1* General.Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be installed in accordance with Section 9.7, as modified by 33.3.3.5.1.1, 33.3.3.5.1.2, and 33.3.3.5.1.3.3.2.1* Approved.Acceptable to the authority having jurisdiction.5.4.3* Installation and Acceptance Testing.Where maintenance or repair requires the replacement of sprinkler system components affecting more than 20 sprinklers, those components shall be installed and tested in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throug..