Eastern Rio Blanco County Health Service District

“The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility’s general characteristics. This facility is a type II (111) single-story structure and is licensed for sixteen (16) residents, The Census was 6 on the day of the survey. The facility is separated from the adjoining skilled nursing and adjoining business occupancy by a 2-hour fire separation. The structure is equipped throughout with a full National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted on April 9, 2024, included an inspection for compliance with the fire safety requirements of Chapter 19 of the National Fire Protection Association (NFPA) -101, Life Safety Code, (2012 edition); NFPA-99, Health Care Facilities Code (2012 edition); and all referenced standards. The survey concluded with a discussion of the deficiencies with the Administrator and the maintenance staff.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 49177 Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by: 1) fire sprinkler gauges dated 2015 need to be replaced 2) The pre-action system needs 3 year full trip testing completed 3) Flow meter gauge dated 2016 due annually for calibration prior to testing 4) 5-year internal on backflow Based on a record review it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Chapter 5 Sprinkler Systems Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25, Chapter 13 Common Components and Valves Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25 8.3.3.1.4 Where 8.3.3.1.2.2 or 8.3.3.1.2.3 is used, the flowmeter shall be adjusted immediately prior to conducting the testing in accordance with the manufacturer ’ s instructions. NFPA 25 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 49177 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by: 1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valves NFPA 54 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods: (1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance (2) As permitted by the authority having jurisdiction (3) In accordance with the manufacturer ’ s installation instructions This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.”

“HVAC - Direct-Vent Gas Fireplaces CFR(s): NFPA 101 Direct-Vent Gas Fireplaces Direct-vent gas fireplaces, as defined in NFPA 54, inside of all smoke compartments containing patient sleeping areas comply with the requirements of 18.5.2.3(2), 19.5.2.3(2). 18.5.2.3(2), 19.5.2.3(2), NFPA 54 This Standard is not met as evidenced by: 49177 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) No carbon monoxide detector installed in “Main Lobby” with with gas fireplace NFPA 101 Heating, Ventilating, and Air Conditioning (101 19.5.2.3(2)(f)): Electrically supervised carbon monoxide detection in accordance with Section 9.8 shall be provided in the room where the fireplace is located. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 49177 Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 99. This was evidenced by: 1) The facility does not inspect wet locations every 6 months as required by NFPA 99 6.3.2.2.8.5. 2) The facility does not meet the record-keeping requirements per NFPA 99 6.3.4.2 NFPA 99 6.3.2.2.8.5(B)(4) (B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows: (1) When first installed (2) Where there is evidence of damage (3) After any repairs (4) At intervals not exceeding 6 months NFPA 99 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 49177 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99. This was evidenced by: 1) Natural ventilation is not sized adequately for the oxygen tank supplying the medical gas room. Mechanical Ventilation will need to be added to this room per NFPA 99 9.3.7.5.3 NFPA 99 9.3.7.5.2.1 Natural ventilation shall consist of two nonclosable louvered openings, each having an aggregate free opening area of at least 155 cm 2/35 L (24 in. 2/1000 ft 3)of the fluid designed to be stored in the space and in no case less than 465 cm 2 (72 in.2). 9.3.7.5.3 Mechanical Ventilation. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft 3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers. 9.3.7.5.3.4 Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system. 9.3.7.5.3.5 Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials. 9.3.7.5.3.6 The exhaust duct material shall be noncombustible. 9.3.7.5.3.7 A means of make-up air shall be provided according to one of the following:(1) Air shall be permitted via noncombustible ductwork to be transferred from adjacent spaces, from outside the building, or from spaces that do not contain combustible or flammable materials via noncombustible ductwork(2) Air shall be permitted to be transferred from a corridor under the door up to the greater of 24 L/sec (50 cfm) or15 percent of the room exhaust in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.(3) Supply air shall be permitted to be provided from any building ventilation system that does not contain flammable or combustible vapors. 9.3.7.6 Discharge from the natural and mechanical ventilation systems shall be sited by a minimum separation distance in accordance with NFPA 55, Compressed Gases, and Cryogenic Fluids Code. 9.3.7.7 A storage room shall maintain a temperature not greater than 52°C (125°F). 9.3.7.8 A transfer or manifold room shall maintain a temperature not greater than 52°C (125°F) and not less than -7°C(20°F). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.”