VI at Highlands Ranch Skilled Nursing

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.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Smoke Deficiencies

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

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.

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

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

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

Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Need fire smoke damper on oxygen room19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).(b)Not less than two separate smoke compartments shall be provided on each floor.(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.This deficiency can potentia.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101No Fire sprinkler semi-annual report at the time of inspection.NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the a.. 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 administrative staff) with the signals and emergency action required under varied conditions.This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This facility is a three-story, Type II (222) structure. The structure is protected throughout by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The structure consists of an assisted living facility on the first (1st) and third (3rd) floors, with the long-term care facility located on the second (2nd) floor. All floors have direct egress to grade level (1st floor on the South and West sides, 2nd floor on the North and Southwest sides, and the 3rd floor on the East side with stair access on the West side). This survey, conducted on October 17, 2024, included a fire safety evaluation under Chapter 19 (Existing Health Care Occupancies) of the 2012 edition of NFPA-101, published by the National Fire Protection Association. The facility is required, for future inspections, to maintain and not diminish the facility features that meet the requirements for new construction at th..

A recertification survey was conducted from 9/16/24 to 9/19/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 9/16/24 to 9/19/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure: -Foods were palatable in temperature; and,-Always available alternative menus were available for residents.Findings include:I. Facility policy and procedureThe Food and Beverage Operation Guide, dated 2024, was received from the nursing home administrator (NHA) on 9/19/24 at 8:00 a.m. It documented in pertinent part, "All food and display units maintain proper temperature to avoid contamination and deterioration. Appropriate times/temperature include: hot food display units must maintain food above 135 degrees Fahrenheit (F). Harmful microbes grow best in the temperature danger zone at 41 to 135 degrees Fahrenheit."II. Individual resident interviewsResident #16 was interviewed on 9/16/24 at 11:26 a.m. She said the food was always served cold when it was served to her in her room. She said she always ate toast for breakfast, and it was served cold and "rock hard." She said she did not enjoy the toast when it was served hard. She said she enjoyed chocolate ice cream with her meals and it often was served melted. She said it took a while to get her meals and they never came at the same time each day. Resident #17 was interviewed on 9/16/24 at 12:04 p.m. ..

Based on field observations, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Missing personal protective equipment for oxygen trans filling operations.NFPA 99 11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable.11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic o.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code section 19.3.4 (2012) and NFPA 72-National Fire Alarm Code (2010). This was evidenced by the following:1. Missing semi-annual fire alarm inspection/testing/maintenance report.2. 7/21/22 Two-year smoke detector sensitivity report does not include manufacturer device tolerance ranges.3. Devices in Elevator Shafts 9 and 10 were not functionally tested during annual fire alarm inspection/testing/maintenance report from 7/5/2022.4. FACP breaker is not labeled in associated electrical panel.5. FACP power supply batteries missing date labels.NFPA 101 19.3.4.1 to comply with section 9.6. Se.. Based on observation during the survey, it was determined that the facility failed to meet the operational requirements in accordance with NFPA 101 (2012). This was evidenced by the following:1. Smoking area materials not disposed of properly in a non-combustible container.NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any otherhazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2) In health care occupancies where smoking is prohibited and signs are prominently placed a.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This facility is a three-story, Type II (222) structure. The structure is protected throughout by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The structure consists of an Assisted Living on the first (1st) and third (3rd) floors with the Long-Term Care located on the second (2nd) floor. All floors have a direct egress to grade level (1st floor on the South and West sides, 2nd floor on the North and Southwest sides, and the 3rd floor on the East side with stair access on the West side). This survey conducted on March 202, 2023, included a fire safety evaluation under Chapter 19 (Existing Health Care Occupancies) of the 2012 edition of NFPA-10.. Through observation during documentation review and field inspection, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25 (2011). This was evidenced by:1. Missing annual fire suppression inspection/testing/maintenance report.NFPA 25 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually.NFPA 25 Chapter 13: Valves, valve components, and trim. 13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the facility administrator and maintenanc..