The Healthcare Resort of Colorado Springs

Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. Multiple smoke and heat detectors were not tested according to the report for the annual alarm inspection. NFPA 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. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or .. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. The delayed egress magnetic locking system on the dining room exit door is inoperative. The audio notification and the release mechanism did not function consistently, proving to be unreliable. NFPA 101, 7.2.1.6.1.1 A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS or PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 30 SECONDS (if approv.. Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105 No current documentation available for review. This inspection is scheduled, the last inspection was 3/30/2021 NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years.6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropr.. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). During the record review, observations and interviews with the maintenance director revealed that there was no written documentation of the continuity of the grounding circuit, the polarity of the hot and neutral connections, and the retention force of the grounding blade in patient care. These assessments were not conducted annually. 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.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is two story, Type V (111), construction. The Long Term Care Facility resides on the 1st floor of the building and is divided into five smoke compartments. The first floor is arranged as a single fire alarm zone with a 2-hour rated construction from an Assisted Living Facility is located on the 2nd floor. There is no basement located under this building. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2016 and is licensed for 97 ..

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of four medications carts and one of one vaccine storage refrigerators... Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. .. Based on observations, record review and interviews, the facility failed to ensure one (#76) of three residents reviewed for activities out of 39 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. .. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for two (#144 and #146) of three residents reviewed for ADLs out of 39 sample residents... Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). .. Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#60 and #74) of three residents reviewed for respiratory care out of 39 sample residents... Based on record review and interviews, the facility failed to ensure physician ordered laboratory services were provided in a timely manner for one (#12) of two residents reviewed for laboratory services out of 39 sample residents... Based on record review and interviews, the facility failed to honor resident choices for residents residing on three of four units of the facility. .. IV. Resident #60 .. *** CITATION TEXT NOT FOUND *** A recertification survey with complaint #CO40094 was conducted on 6/23/25 to 6/26/25. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 6/23/25 to 6/26/25. No deficiencies were cited. ..