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This portion applies to Building A-3, known as Building C.

It was determined by observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

The corridor doors in the following resident rooms failed to positively latch into the door frame assembly, as required by 19.3.6.3.2:
a) resident room #136,
b) resident room #140, and
c) resident room #141.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) The corridor doors in the following resident rooms failed to positively latch into the door frame assembly, as required by 19.3.6.3.2:
a) resident room #130,
b) resident room #131,
c) resident room #133, and
d) resident room #143.

2) the corridor door serving the seclusion room #149 has two holes through the top of the door, failing to limit the transfer of smoke or the products of combustion.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation during the survey that the facility failed to maintain the smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier wall serving the sleeping wings was found to have two unsealed penetrations above the drop ceiling on the north sleep wing side of the barrier.
Note: This item was corrected during the survey.

The smoke barrier wall deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation during the survey that the facility failed to maintain the doors serving a smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier door for the north sleep wing corridor has four (4) unsealed penetrations at the top of the door that would fail to limit the transfer of smoke or the products of combustion.
Note: This item was corrected during the survey.

The smoke barrier door deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation during the survey that the facility failed to maintain the doors serving a smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier door for the east sleep wing corridor has four (4) unsealed penetrations at the top of the door that would fail to limit the transfer of smoke or the products of combustion.
Note: This item was corrected during the survey.

The smoke barrier door deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation during the survey that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

Two (2) of two (2) sleeping wing smoke barrier doors (doors that serve as a required means of egress) are equipped with a magnetic locking function that failed to unlock upon activation of the fire alarm system in accordance with 18.2.2.2.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation and document review during the survey that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the third quarter of 2012,
b. One (1) during the second shift in the second quarter of 2012,
c. One (1) during the first shift in the second quarter of 2012, and
d. One (1) during the second shift in the fourth quarter of 2011.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation and document review during the survey that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the third quarter of 2012,
b. One (1) during the first shift in the third quarter of 2012,
c. One (1) during the first shift in the second quarter of 2012,
d. One (1) during the first shift in the second quarter of 2012, and
e. One (1) during the second shift in the fourth quarter of 2011.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

The facility failed to provide documentation at the time of the survey to reflect that water flow alarms for the automatic fire sprinkler system were tested during the third quarter of 2012.
Note: The water flow alarms are required to be tested quarterly in accordance with NFPA 25, 2-3.3.

The fire sprinkler system deficiency item was discussed during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

The facility failed to provide documentation at the time of the survey to reflect that water flow alarms for the automatic fire sprinkler system were tested during the third quarter of 2012.
Note: The water flow alarms are required to be tested quarterly in accordance with NFPA 25, 2-3.3.

The fire sprinkler system deficiency item was discussed during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by record review and staff interview during the course of the survey that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4, and referenced NFPA 110, Standard for Emergency and Standby Power Systems, chapter 6. This was evidenced by the following:

The facility provided documentation at the time of the survey to reflect that the generator had been run under load monthly; however, as required by NFPA 99, section 3-4 and NFPA 110, section 6-4, the load placed on the generator was not greater than 30% of the generator's nameplate rating. In accordance with 6-4.2.2, the exercise of this diesel generator must be supplemented annually with a load bank test - the facility failed to provide documentation at the time of the survey to reflect that this required service had been performed in the past year.

The emergency power supply system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by record review and staff interview during the course of the survey that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4, and referenced NFPA 110, Standard for Emergency and Standby Power Systems, chapter 6. This was evidenced by the following:

1) The facility provided documentation at the time of the survey to reflect that the generator had been run under load monthly; however, as required by NFPA 99, section 3-4 and NFPA 110, section 6-4, the load placed on the generator was not greater than 30% of the generator's nameplate rating. In accordance with 6-4.2.2, the exercise of this diesel generator must be supplemented annually with a load bank test - the facility failed to provide documentation at the time of the survey to reflect that this required service had been performed in the past year.

2) The required battery backed-up emergency light located at the transfer switch failed to illuminate when the button marked as "push to test" was depressed.

The emergency power supply system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation during the course of the survey that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code.

The facility had a surge protected electrical power strip plugged into a six-outlet multiple use electrical socket without over current protection in the main office near the copy machine.

The electrical system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to reflect that the affected area must be inspected, at a minimum, every fifteen minutes (the document provided required a thirty-minute inspection).
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes and that the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division shall be notified of at the outset and completion of fire watch.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to reflect that the affected area must be inspected, at a minimum, every fifteen minutes (the document provided required a thirty-minute inspection).
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes and that the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division shall be notified of at the outset and completion of fire watch.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

The corridor doors in the following resident rooms failed to positively latch into the door frame assembly, as required by 19.3.6.3.2:
a) resident room #136,
b) resident room #140, and
c) resident room #141.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety Code. This was evidenced by:

1) The corridor doors in the following resident rooms failed to positively latch into the door frame assembly, as required by 19.3.6.3.2:
a) resident room #130,
b) resident room #131,
c) resident room #133, and
d) resident room #143.

2) the corridor door serving the seclusion room #149 has two holes through the top of the door, failing to limit the transfer of smoke or the products of combustion.

The corridor door deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation during the survey that the facility failed to maintain the smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier wall serving the sleeping wings was found to have two unsealed penetrations above the drop ceiling on the north sleep wing side of the barrier.
Note: This item was corrected during the survey.

The smoke barrier wall deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation during the survey that the facility failed to maintain the doors serving a smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier door for the north sleep wing corridor has four (4) unsealed penetrations at the top of the door that would fail to limit the transfer of smoke or the products of combustion.
Note: This item was corrected during the survey.

The smoke barrier door deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation during the survey that the facility failed to maintain the doors serving a smoke barrier wall in accordance with the 2000 edition of NFPA 101, the Life Safety Code?. This was evidenced by:

The smoke barrier door for the east sleep wing corridor has four (4) unsealed penetrations at the top of the door that would fail to limit the transfer of smoke or the products of combustion.
Note: This item was corrected during the survey.

The smoke barrier door deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation during the survey that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

Two (2) of two (2) sleeping wing smoke barrier doors (doors that serve as a required means of egress) are equipped with a magnetic locking function that failed to unlock upon activation of the fire alarm system in accordance with 18.2.2.2.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation and document review during the survey that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the third quarter of 2012,
b. One (1) during the second shift in the second quarter of 2012,
c. One (1) during the first shift in the second quarter of 2012, and
d. One (1) during the second shift in the fourth quarter of 2011.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation and document review during the survey that the facility failed to perform fire drills in accordance with the Life Safety Code. This was evidenced by:

Documentation was not provided at the time of the survey to show the following drills had been completed:
a. One (1) during the second shift in the third quarter of 2012,
b. One (1) during the first shift in the third quarter of 2012,
c. One (1) during the first shift in the second quarter of 2012,
d. One (1) during the first shift in the second quarter of 2012, and
e. One (1) during the second shift in the fourth quarter of 2011.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

The facility failed to provide documentation at the time of the survey to reflect that water flow alarms for the automatic fire sprinkler system were tested during the third quarter of 2012.
Note: The water flow alarms are required to be tested quarterly in accordance with NFPA 25, 2-3.3.

The fire sprinkler system deficiency item was discussed during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation and record review during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

The facility failed to provide documentation at the time of the survey to reflect that water flow alarms for the automatic fire sprinkler system were tested during the third quarter of 2012.
Note: The water flow alarms are required to be tested quarterly in accordance with NFPA 25, 2-3.3.

The fire sprinkler system deficiency item was discussed during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by record review and staff interview during the course of the survey that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4, and referenced NFPA 110, Standard for Emergency and Standby Power Systems, chapter 6. This was evidenced by the following:

The facility provided documentation at the time of the survey to reflect that the generator had been run under load monthly; however, as required by NFPA 99, section 3-4 and NFPA 110, section 6-4, the load placed on the generator was not greater than 30% of the generator's nameplate rating. In accordance with 6-4.2.2, the exercise of this diesel generator must be supplemented annually with a load bank test - the facility failed to provide documentation at the time of the survey to reflect that this required service had been performed in the past year.

The emergency power supply system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by record review and staff interview during the course of the survey that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4, and referenced NFPA 110, Standard for Emergency and Standby Power Systems, chapter 6. This was evidenced by the following:

1) The facility provided documentation at the time of the survey to reflect that the generator had been run under load monthly; however, as required by NFPA 99, section 3-4 and NFPA 110, section 6-4, the load placed on the generator was not greater than 30% of the generator's nameplate rating. In accordance with 6-4.2.2, the exercise of this diesel generator must be supplemented annually with a load bank test - the facility failed to provide documentation at the time of the survey to reflect that this required service had been performed in the past year.

2) The required battery backed-up emergency light located at the transfer switch failed to illuminate when the button marked as "push to test" was depressed.

The emergency power supply system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation during the course of the survey that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code.

The facility had a surge protected electrical power strip plugged into a six-outlet multiple use electrical socket without over current protection in the main office near the copy machine.

The electrical system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-3, known as Building C.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to reflect that the affected area must be inspected, at a minimum, every fifteen minutes (the document provided required a thirty-minute inspection).
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes and that the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division shall be notified of at the outset and completion of fire watch.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A-4, known as Building D.

It was determined by observation, staff interview, and through record review during the course of the survey that the facility failed to provide an acceptable fire watch policy in the event the automatic fire sprinkler system is out of service for more than 4 hours in a 24-hour period. This was evidenced by the following:

At the time of the survey the facility provided a policy and documentation enacting the policy regarding the requirement set forth in NFPA 101, 9.7.6.1, wherein it states that when a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the building shall be evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. The documentation failed to reflect that the affected area must be inspected, at a minimum, every fifteen minutes (the document provided required a thirty-minute inspection).
Note: In accordance with the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division's (Authority Having Jurisdiction) policy manual in regards to Life Safety Code Fire Watch Requirements (enacted in January of 2010), a full inspection of the affected areas within this facility shall take place at a minimum of every fifteen minutes and that the Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Service Division shall be notified of at the outset and completion of fire watch.

The fire watch policy deficiency item was discussed during the survey and again during the exit conference.