Veterans Community Living Center at Fitzsimons

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

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.

Services Deficiencies

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

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Resident Rights Deficiencies

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

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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

Install a fire alarm system that can be heard throughout the facility.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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

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.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

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

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

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

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.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Services Deficiencies

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

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Based on a 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 Section 9.6 and NFPA 72.The kitchen patio south strobe falling off the wall9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with .. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain fire doors in accordance with Life Safety Code and NFPA 80.The fire door inspection conducted showed C100C, stair 4, B-203 dinning room, Stair 2 B208, D100, D100C, Stair 1 b100, Stair 1 B200. Repairs were not corrected at the time of inspec.. 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 105Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required one year after the initial .. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 4.6.12. The therapy mechanical room, has California three patches in the ceiling.4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, .. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen Transfill rooms need a vent 12" of the floorNFPA 556.15.7 Inlets to the Exhaust System.6.15.7.1 The exhaust ventilation system design shall take into accou.. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. At the time of the survey no documentation or records that all fire extinguishers through-out the facility were subjected to annual inspections.Life Safety Code 101, 2012 Edition, section 9.7.4. Wher.. Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. 1. Oxygen is stored in egress.2. Oxygen stored in the walkway of the exterior door of the maintenance shopNFPA 99 11.3.2.1Storage locations shall be outdoors in an enclosure or within an enclosed interior s.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and admi.. The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a).The facility is a two story, Type II (111), protected non-combustible structure and is protected throughout by an automati.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. wires on sprinkler pipe a-126 central supply2. Need quarterly reports3. First-floor heritage room c14a valve flowing during semi-annual July 1st, 20244.D-221 gap e.. 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:Christmas decorations were throughout the path of egress. During the inspection, the facility did not have proof of fire-resistive protection or that the decor..

A recertification survey with Incident #37854, #38506, #38507, #38508 and #38510 was completed on 11/18/24 to 11/21/24. Eight deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited. Based on observations, record review and interview, the facility failed to assist a resident in obtaining routine or emergency dental services, as needed for three (#81, #45, and #93) out of 45 sample residents.Specifically, the facility failed to:-Ensure a referral to dental services was completed three days after Resident #81 broke two of his t.. Based on observations, record review and interviews, the facility failed to ensure four (#127, #60, #45 and #92) of five residents reviewed for abuse out of 45 sample residents were kept free from abuse.Specifically, the facility failed to:-Prevent resident to resident physical abuse between Resident #127 and Resident #60, who had a known history of.. Based on observations, record review and interviews, the facility failed to promote and maintain the resident' s dignity for one (#65) of one resident reviewed for dignity and respect out of 45 sample residents.Specifically, the facility failed to ensure call light was in reach for Resident #65' s use with limited range of motion.Findings include:I. Residen.. Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#10) of one resident out of 45 sample residents. Specifically, the facility failed to provide food choices according to Resident #10' s preference.Findings include:I. Resident #10A. Resident statusResident #10, age gr.. Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicatable diseases and infections.Specifically, the facility failed to:-Ensure t.. Based on observations, record review, and interviews, the facility failed to revise and review comprehensive care plans for five (#122, #104, #81, #46 and #65) of 11 residents reviewed out of 45 total sample residents. Specifically, the facility failed to:-Ensure Resident #122, Resident #104 and Resident #81' s care plans were reviewed and revised t.. Based on record review and interviews, the facility failed to ensure one (#45) of one resident, out of 45 sample residents, with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. Specifically, the facility failed to ensure the physician' s order for Resident #45 to use the facility' s .. Based on record review, observation and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#65) of three residents reviewed out of 45 sample residents.Specifically, the facility failed to ensure a certified nurse aide (CNA) reported Resident #65' s new skin alter..