Lennox Guest Home, the

A life safety code survey, prompted by #CO39958, was completed on 5/09/2025. Five deficiencies were cited. The facility is a one (3) story, Type V (000) wood frame structure with a basement and licensed for fifty-five (55) residents. The facility is not equipped with a fire suppression system.This survey, conducted on May 9, 2025, included a fire safety evaluation under Chapter 33 of the 2012 edition of NFPA-101 for existing large facilities. Based on observation and interview, it was determined that the facility failed to arrange and maintain fire doors in accordance with Life Safety Code 101. The deficient practice affected all smoke compartments, 51 of 51 residents, and an indeterminable number of staff and visitors.Observation with the building owner revealed the following:1. The front entrance was locked against egress by a deadbolt.2. The back door was locked against egress by a deadbolt.3. The west sun porch was locked against egress by a deadbolt.The building owner acknowledge the three doors were locked against egress with a deadbolt.33.3.2.2.2 Doors.Doors in means of egress shall be as follows:(1)Doors complyi.. Based on observation and interviews with the facility owner, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 54. The deficient practice affected all smoke compartments, residents, staff and visitors to the facility.A staff member reported smelling a gas odor in the mechanical room.During an interview and observation with the facility owner acknowledge there was gas odor. The owner called a plumber to the facility.Upon inspection of the facility gas piping, the plumber reported the whole gas piping system had leaks at all joints.NFPA 548.1.1.3 Where repairs or additions are made following the pressure test,.. Based on observation and interviews, it was determined that the facility failed to implement a smoking policy in accordance with the Life Safety Code 101. The deficient practice affected all smoke compartments, 51 of 51 residents, and indeterminable number of staff and visitors.During an interview and observation with the facility owner, evidence of smoking was discovered in the building' s basement, in rooms 350 and 302, on the sun patio, and on the second-floor deck. The owner acknowledged the evidence smoking was present the basement; room 302 and 350; the sun patio; and on the second floor deck.33.7.4 Smoking.33.7.4.1* Smoking regulations shall be adopted by the ad.. Based on observation, interview, and record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments, 51 of 51 residents, and an indeterminable number of staff and visitors.The facility was observed with the building owner. The following concerns were identified:1. The fire alarm panel revealed seven problems with the system.2. The fire alarm was not programmed correctly and the supervisory alarms did not direct one to the correct location.3. The fire panel has never been inspected. 4. The fire alarm strobe.. Based on observation, interview, and record review, the facility failed to maintain a facility constructed in conformity with the standards adopted by the Division of Fire Prevention and Control (DFPC) related to residential board and care occupancies. Specifically, the facility failed to comply with requirements for maintaining the life safety code for fire alarm, means of egress, gas code, and smoking policy. The facility failures had the potential to affect all occupant of the building.Findings include:Cross-reference to A0001 for observations and interviews of smoking activities in violation of applicable codes.Cross-reference to A0002 for observation, interview, and record review of the fire alar..

A licensure complaint, prompted by by #CO39033, #CO39951 and #CO39953, was completed on 5/13/25. Deficiencies were cited. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 54 current residents. (Cross-reference T920, T1110)Specifically, the residence did not maintain the Colorado Clean Indoor Air Act and residents were not smoking 25 feet from the residence. The residents were also smoking marijuana throughout the residence' s property. The residence also had two enclosed smoking areas attached to the building where residents regularly smoked. Multiple residents were found smoking cigarettes and marijuana inside their bedrooms. Additionally, the residence had a gas leak. This failure created an immediate jeopardy risk of harm to all 54 current residents residing in the residence. Findings include:ObservationsOn 5/8/25 at approximately 10:45 a.m., during an environmental tour multiple residents were smoking cigarettes and marijuana in designated non-smoking areas of the residence. These areas included an upper b.. Based on observation, record review, and interview, the residence failed to either directly or indirectly provide protective oversight, personal services and a physically safe and sanitary environment, affecting 54 current residents. (Cross-reference T920, T2720)Specifically, on 5/8/25 the residence' s fire panel read there was trouble with the system, affecting the smoke detectors throughout the entire residence. Therefore, the smoke detectors were ineffective and would not have sent an accurate signal to the fire panel and its monitoring system to set off the residence' s alarm in the event of smoke or fire. The residence also had a significant gas leak issue where gas odor could be smelt throughout the residence. On 5/8/25, the department directed the residence to provide written evidence that the risk had been removed. Additionally, a representative from the local fire authority (LFA) stated that the residence had never had their fire panel tested or inspected hence it had no approval from the LFA. Lastly, the r.. Based on observations, record review, and interview the residence failed to ensure that the residence' s emergency policies included the circumstances and procedures to evacuate the premises, assignment of specific staff duties on each shift using triage to identify the most vulnerable residents, or agreements with other residences in the event of relocation of residents, affecting 54 current residents. (Cross-reference T1110, T2720)Specifically, the residence did not establish clear evacuation procedures. There is no predetermined system for communication with residents, families, staff and external providers, which could lead to confusion and delays in critical situations. Furthermore, the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence t..

A certification complaint, prompted by #CO39034, #CO39950 and #CO39952, was completed on 5/13/25. Deficiencies were cited. Based on observation and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting 54 current residents. (Cross-reference B808, B1702)Specifically, the residence did not maintain the Colorado Clean Indoor Air Act and residents were not smoking 25 feet from the residence. The residents were also smoking marijuana throughout the residence' s property. The residence also had two enclosed smoking areas attached to the building where residents regularly smoked. Multiple residents were found smoking cigarettes and marijuana inside their bedrooms. Additionally, the residence had a gas leak. This failure created an immediate jeopardy risk of harm to all 54 current residents residing in the residence. Findings include:ObservationsOn 5/8/25 at approximately 10:45 a.m., during an environmental tour multiple residents were smoking cigarettes and marijuana in designated non-smoking areas of the residence. These areas included an upper b.. Based on observation, record review, and interview, the facility (residence) failed to monitor its members to assure health, safety and well-being, affecting 54 current members (residents). (Cross-reference B164, B808)Specifically, on 5/8/25 the residence' s fire panel read there was trouble with the system, affecting the smoke detectors throughout the entire residence. Therefore, the smoke detectors were ineffective and would not have sent an accurate signal to the fire panel and its monitoring system to set off the residence' s alarm in the event of smoke or fire. The residence also had a significant gas leak issue where gas odor could be smelt throughout the residence. On 5/8/25, the department directed the residence to provide written evidence that the risk had been removed. Additionally, a representative from the local fire authority (LFA) stated that the residence had never had their fire panel tested or inspected hence it had no approval from the LFA. Lastly, the residence' s elevator had currently been non operational.. Based on observations, record review, and interview the facility (residence) failed to have a documented contingency plan for providing services if the residence staff was unavailable due to an emergency circumstance, affecting 54 current members (residents). (Cross-reference B164, B1702) Specifically, the residence did not establish clear evacuation procedures. There is no predetermined system for communication with residents, families, staff and external providers, which could lead to confusion and delays in critical situations. Furthermore, the residence did not have signed written documents with other facilities or community agencies in case the residents needed to be relocated. This failure created an immediate jeopardy risk due to a lack of emergency preparedness procedures for all 54 current residents residing in the residence. On 5/9/25, the department directed the residence to provide written evidence that the risk had been removed.Finding include:ObservationsOn 5/8/25 at approximately 2:15 p.m., Reside..

A revisit survey was completed on 9/05/24 for all previous deficiencies cited on 7/01/24. The facility is in compliance with all deficiencies that were cited. 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

A revisit survey was completed on 9/05/24 for all previous deficiencies cited on 7/01/24. The facility is in compliance with all deficiencies that were cited. 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