Suites at Holly Creek Care Center, the

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

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

Quality of Life and Care Deficiencies

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

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Quality of Life and Care Deficiencies

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

Egress Deficiencies

Install proper backup exit lighting.

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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.

Smoke Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Egress Deficiencies

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

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

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

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Based on observation during the survey, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2. This was evidenced by the following:1. The residential laundry room (hazardous area) is not protected with a self-closing doorNFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.NFPA 80 5.2.14.1 Self-closing devices shall be kept in working conditionat all time.. Based on observation of the fire alarm panel it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. This was evidenced by the following:1. There is a trouble on the fire alarm panel. The battery associated with the Trouble was replaced, and the Trouble Status was temporarily cleared. The Trouble Status returned after the new battery was installed and was evident during the time of the survey. 2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.Failure to m.. The Colorado Department of Fire Prevention and Control survey of The Suites at Holly Creek Care Center was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a). The Initial comments, (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.The facility is a two-story Type II (111), construction with a basement used for support services and parking only. This building contains other occupancies and they are properly protected to be separate occupancies. The basement has an exterior exit to grade level. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 and 13R automatic fire suppression systems and is classified as Fully Sprinkled. The facility was constructed in 2008 and is lice.. Through observation during the survey, it was determined that the facility failed to meet the Combustible Decorations requirements in accordance with NFPA 101, 19.7.5.6. This was evidenced by the follwoing:1. Christmas decorations (Christmas trees and wreaths) do not have evidence of being fire-rated.NFPA 101, 19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:(1)They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.(2)The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.(3)The decorations exhibit a heat release rate not exceeding 100 kW whe.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by the following:1. Loaded fire sprinkler heads (lint build-up) in rooms 4135, 4131, 4117.2. Fire sprinkler heads and escutcheons are dropping down (not flush to the ceiling, leaving a gap) in rooms 4114 and 4115.NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around ..

Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on 7/15/24 for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. Preventative measures to protect the resident' s heels were not implemented until after the development of the blister on 8/2/24. On 9/6/24, a physician' s progress note documented the resident' s left heel had developed eschar (dead tissue). On 11/7/24, when the wound care physician took over care (three months after the blister was initially identified), the wound was classified as an unstageable ulcer to the left heel. Due to the facility' s failure to implement effective pressure injury interventions in a timely manner, Resident #6 developed a facility-acquired unstageable pressure injury to her left heel. Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 11/24/24 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmente.. A licensure survey was completed on 11/18/24 to 11/21/24. One deficiency was cited.

A recertification survey was conducted from 11/18/24 to 11/21/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure staff followed appropriate infection control practices while cleaning resident rooms. Findings include:I. Failure to ensure staff donned appropriate PPE when providing care to a resident on EBPA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) About Enhanced Barrier Precautions (EBP) I.. Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on 7/15/24 for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. Preventative measures to protect the resident' s heels we.. Based on observations, record review and interviews, the facility failed to ensure two (#4 and #10) of two of 20 sample residents remained free from accidents hazards.Specifically, the facility failed to ensure Resident #4 and Resident #10 had a physician' s order, a consent and a completed safety assessment before the implementation of a floor to ceiling transfer pole by the resident' s bed.Findings include:I. Facility policy and procedureThe Bed Mobility Devices policy, approved October 2024, was provided by the nursing home administrator (NHA) on 11/20/24 at 10:30 a.m. The policy revealed bed mobility devices had the potential to cause actual harm or entrapment to residents. The facility would follow the recommendations and guidelines as outlined to ensure resident safety and the appropriate use of the devi..