FAIRACRES MANOR, INC.

A complaint survey, prompted by #CO2693387 was conducted on 12/16/25. No deficiencies were cited.

A survey prompted by complaint #CO2693388 was completed 12/16/25. No deficiencies were cited.

A revisit to the 7/2/2024 survey was completed on 10/11/2024. The facility was in compliance with the regulations surveyed.

A revisit survey was completed on 7/3/24 for all previous deficiencies cited on 6/6/24. The facility is in compliance with all regulations surveyed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on July 2. 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies." This structure is a one (1) story wood frame structure with Type V (000) construction and a partial basement. Residents have access to the basement area for hair salon services. This facility was built in 1966. The facility is licensed for 116 beds, and the census on the survey date was 99. The facility is fully sprinkled and protected throughout by National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler systems. The survey results were discussed with the Environmental Director and the Assistant Administrator during the exit conference conducted on July 2. 2024.

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. South patio Gates missing exit signsNFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. NFPA 101 7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment. These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96 (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. 1. Commercial cooking equipment under a suppression system does not have wheel blocks installed. 2. Commercial cooking equipment on casters does not have restraint devices installed. NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator discussed deficient items at the exit conference.

Through observation and staff interviews of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes in accordance with NFPA101 Life Safety Code (2012 Edition), section 19.3.3.1 and 10.2. 1. Basement break room ceiling tiles missing. 2. Laundry ceiling tiles missing19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section10.2 shall be permitted to be Class A or Class B.Through observation during the survey, it was determined that the facility failed to meet theprotection requirements in accordance with NFPA 101. This was evidenced by:1) Temporary isolation wall on the second floor COVID-19 Positive Unit wing did not have aninterior finish classification in accordance with Section 10.2. Life Safety Code section 19.3.3.1 to comply with section 10.2. Section 10.2.3 requires, in part,interior wall and ceiling finish that is required elsewhere in the Code to be Class A, Class B, orClass C shall be classified based on the test results from ASTM E 84. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.

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 101 and NFPA 72. 1. The 2-year sensitivity report has most of the devices listed as not tested 2. Fire alarm report deficiencies: batteries throughout need to be replaced, two annunciator panels failed, programming errors, smoke detectors, and heat detectors failed, and pull stations failed. 3. No fire alarm Semi-annual report at the time of inspection. 2012 Life Safety Code 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 CodeNFPA 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 smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionNFPA 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 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashesThis deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observations and records review, it was determined that the facility did not have out-of-service guidance for the fire alarm in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not have proper verbiage NFPA 101 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. These deficiencies can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

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. No 3-year dry valve inspection at the time of inspection. 2. Loaded heads: Bistro, Kitchen. 3. Missing escutcheon: basement north stairwell, basement break room. 4. Fire backflow leaking. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 10.10.2.5.1 The backflow prevention assembly shall be forward flow tested to ensure proper operation. 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 throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 25Out-of-service Sprinkler Guidance - Does not have proper verbiage. NFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) The extent and expected duration of the impairment have been determined.(2) The areas or buildings involved have been inspected and the increased risks determined.(3) Recommendations have been submitted to management or the property owner or designated representative.(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:(a) Evacuation of the building or portion of the building affected by the system out of service(b) *An approved fire watch(c)*Establishment of a temporary water supply(d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire(5) The fire department has been notified.(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.(7) The supervisors in the areas to be affected have been notified.(8) A tag impairment system has been implemented. (See Section 15.3.)(9) All necessary tools and materials have been assembled on the impairment site. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31. Fire doors near 301 need a sill. 2. Smoke seal room111NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. The maintenance director and administrator discussed deficient items during the survey and at the exit conference.

STANDARD is not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas in accordance with Life Safety Section 19.3.2.1. and 9.5The laundry chute door shall be fire-rated. 9.5.1.2 Inlet openings serving chutes shall be protected in accordance with Section 8.3.8.3.1.1 Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance with one of the following fire resistance ratings:(1) 3-hour fire resistance rating(2) 2-hour fire resistance rating(3) 1-hour fire resistance rating(4)* 1/2-hour fire resistance rating8.3.1.2* Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. NFPA 101 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service. This deficient practice could affect all residents and staff in all the main smoke compartments should smoke and heat transfer between the hazardous area and other portions of the building occur. Deficient items were discussed with the Maintenance Director at the exit conference.

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 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 can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and maintenance director discussed deficient items at the exit conference.

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). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was 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 verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following. 1. The facility failed to provide documentation during the survey to reflect that the emergency generator was inspected weekly. 2. No transfer time for the generator. 8.4.6 Transfer switch shall be operated monthly. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1) Extension cord supplying power appliances in the HR officeFlexible cords and cables in accordance with Chapter 4 of NFPA 70, Section 400.8(1), in part, flexible cords and cables shall not be used as a substitute for the fixed wiring of a structure. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."This deficiency can potentially affect the occupants, including the residents, staff, and visitors within affected smoke compartments. The maintenance staff and facility administrator discussed deficient items during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" of the floor. 2. The cylinder in the oxygen storage room shall be labeled empty full. 3. Upstairs riser room e-tanks shall to be in oxygen storage room5.1.3.3.4.1 Full or empty medical gas cylinders, when not connected, shall be stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3 and shall be permitted to be in the same rooms or enclosures as their respective central supply systems. NFPA 556.15.7 Inlets to the Exhaust System. 6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released. 6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. 6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the ceiling. NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator and Maintenance director discussed deficient items at the exit conference.

A recertification survey with complaint #CO35647 was completed on 6/3/24 to 6/6/24. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/3/24 to 6/6/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to:-Follow the weekly menu to ensure adequate nutrition was provided to the residents; and, -Ensure Resident #38 and Resident #10 were provided with the correct mechanically altered diet. Findings include:I. Failure to follow the weekly menu to ensure adequate nutrition was provided to the residents A. Observations and record reviewReview of the menu and the menu extensions for the 6/3/24 lunch meal revealed that 2% (percent) milk was to be served. On 6/3/24 the lunch service was observed during a continuous observation in the main and rear dining rooms, beginning at 10:50 a.m. and ending at 11:58 p.m. -The dietary aides in the main and rear dining rooms did not offer residents milk as a beverage during the observation period, but offered soda and juice instead. Review of the menu and menu extensions for the 6/3/24 dinner meal revealed that a side of tartar sauce was to be served to all residents and 2% milk was to be served..The altered texture menu extension revealed residents receiving altered diet textures were to receive pasta salad in place of the regular menu's potato chips. On 6/3/24 the dinner service was observed during a continuous observation in the kitchen, beginning at 4:30 p.m. and ending at 6:25 p.m. Observations revealed the following:-Only one resident was served a side of tartar sauce; and,-Cook (CK) #1 served a scoop of mashed potatoes to the minced and moist, soft and bite-sized and puree altered diet textures as a substitute for the potato chips on the regular menu instead of the pasta salad that was to be served. The 6/3/24 dinner service was observed during a continuous observation in the main and rear dining rooms, beginning at 4:45 p.m. and ending at 5:50 p.m. The dietary aides in the main and rear dining rooms did not offer residents milk as a beverage during the observation period, but offered soda and juice instead.-Menu nutritional information was requested from the regional dietary consultant (RDC) on 6/5/24 at 4:05 p.m. but was not received by the survey exit date on 6/6/24. B. Resident group interviewOn 6/4/24 at 3:05 p.m. a group interview was conducted with three residents (#15, #42 and #21) who frequently attended monthly resident council meetings and were identified as interviewable by the facility and assessment. All residents in attendance said they only received milk at meals when they asked for it and that no alternative dairy products were offered in place of milk. All residents in attendance said menu items changed without informing the residents, and the residents would not know what they would be eating until it was served. C. Staff interviewsDietary aide (DA) #2 was interviewed on 6/3/24 at 5:45 p.m. DA #2 said the dietary aides asked residents what they wanted to drink. DA #2 said she was not told if a beverage was on the menu. DA #2 said dietary aides did not offer alternatives if a resident did not select milk as their beverage during meals. The registered dietitian (RD) was interviewed on 6/4/24 at 2:05 p.m. The RD said everything on the menu needed to be served. The RD said milk was offered to residents but they did not have to take it.-However, observations revealed residents were not offered a choice of milk during the meals (see observations above). The RDC was interviewed on 6/5/24 at 4:05 p.m. The RDC said tartar sauce was never given during meals, especially not for menu items like tuna melt sandwiches.-However, tartar sauce was listed on the menu for the 6/3/24 dinner meal (see record review above). II. Failure to ensure residents were served the correct mechanically altered dietsA. Professional referenceThe International Dysphagia Diet Standardization Initiative (IDDSI) altered texture diet information, revised 7/31/2019, was retrieved on 6/12/24 from www.iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf. It read in pertinent part, "For level six soft and bite sized texture, no regular dry bread, sandwiches or toast of any kind."Level five minced and moist texture meat should be finely minced or chopped. (Pieces of meat should be) equal to or less than four millimeters in width and no more than 15 millimeters in length. Serve in mildly, moderately or extremely thick, smooth, sauce or gravy."B. Facility policy and procedureThe Therapeutic Diets policy, revised 4/2023, was provided by the nursing home administrator (NHA) on 6/6/24 at 11:34 a.m. It read in pertinent part, "Therapeutic diets must be prescribed by the attending physician."When a therapeutic diet is ordered, it is served correctly. Therapeutic diets are physician orders and must be followed."C. Observations and record reviewReview of the altered texture menu extensions for the 6/3/24 dinner meal revealed residents receiving altered diet textures were to receive tuna and noodles which had been food processed instead of the regular texture tuna melt sandwich. On 6/3/24 the dinner service was observed during a continuous observation in the kitchen, beginning at 4:30 p.m. and ending at 6:25 p.m. At 5:40 p.m. cook (CK) #1 prepared Resident #38's meal, which included a regular texture tuna melt sandwich served between two pieces of toasted plain white bread. Upon prompting, the registered dietitian (RD) removed the sandwich from Resident #38's plate and replaced it with the soft and bite-sized textured meal item (see menu extension above). At 5:50 p.m. dietary aide (DA) #1 prepared Resident #10's meal, which included a deli ham and cheese sandwich served between two pieces of toasted plain white bread. The ham was sliced deli meat and was not mechanically altered. Upon prompting the RD removed the sandwich from Resident #10's plate and it was replaced with a sandwich with minced and moist meat.-However, without prompting Resident #38 and Resident #10 would have been served a regular texture meal. D. Staff interviewsThe RD was interviewed on 6/3/24 at 5:40 p.m. The RD said Resident #38 could not have bread due to her prescribed diet texture of soft and bite sized. The RD said the sandwich originally made for Resident #10 did not have the correct texture of meat within the sandwich. The RD was interviewed again on 6/4/24 at 2:05 p.m. The RD said there was a three point system to ensure residents got the correct diet texture that started with the cook, followed by the dietary aide, then the certified nurse aide (CNA) that served the resident's food. The RD said she frequently watched the kitchen tray line and saw the kitchen staff follow the mechanically altered diet orders. The RD was interviewed again on 6/5/24 at 9:13 a.m. The RD said she provided education on 6/5/24 (during the survey) to the kitchen staff on the IDDSI diet textures. The RD said her education emphasized that residents with an IDDSI texture less than seven could not receive bread products. The regional dietary consultant (RDC) was interviewed on 6/5/24 at 4:05 p.m. The RDC said soft and bite-size diet textures should have food pieces approximately 15-17 millimeters in size. The RDC said some residents could tolerate bread and serving bread products was left to the decision of the RD.Licensed practical nurse (LPN) #2 was interviewed on 6/6/24 at 11:24 a.m. LPN #2 said she had not received any education on altered diet textures and what they included. LPN #2 said altered textures prevented aspiration and choking risks for residents with difficulty swallowing. LPN #2 said Resident #38 had issues with swallowing. The speech language pathologist (SLP) was interviewed on 6/6/24 at 12:02 p.m. The SLP said the facility transitioned to IDDSI diet texture structures in October 2023. The SLP said residents often received downgrades in diet textures due to issues with dentition, mentation and of ease of swallowing. The SLP said Resident #38 was ordered for an altered texture diet on 6/8/23 and changed to a soft and bite-size texture diet on 10/16/23. The SLP said bread products were deemed safe for Resident #38 because she was on an IDDSI level six diet, but that the sandwich should have been cut up into pieces 1.5 to 2 inches in size. The SLP said if the cooks and dietary aides did not provide the residents with the correct diet texture it could potentially result in choking, occlusion or aspiration pneumonia. The SLP said he had not done a formal speech evaluation for any of the residents on altered texture diets as they had not had any incidents that indicated they needed an evaluation. The SLP said Resident #10 had issues with his dentition. The SLP said Resident #10 was prescribed to receive an altered meat texture on 5/24/23. The SLP said any kind of meat that was not ground was fibrous and therefore more difficult to chew. The SLP said whenever residents had dentition issues he wanted to make sure things were not getting stuck. He said Resident #10 had not had any choking incidents. The SLP said there were no indicators that Resident #10 would have issues chewing deli slices of meat, but that meat should be ground up because it was easier for him to chew. IV. Performance improvement planA performance improvement plan and subsequent root cause analysis, initiated 3/15/24, was received from the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part: "Problem: Therapeutic diets not followed. Root cause: staff not checking therapeutic menu. "Action plan to correct issues identified: education on therapeutic menu. Responsible team members: RD and dietary manager. Start date: 3/20/24. Estimated completion date: 3/25/24."-However, the performance improvement plan addressed concerns with therapeutic diets and not mechanically altered diets.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to:-Ensure safe holding temperatures for food items were maintained;-Ensure kitchen staff wore appropriate hair restraints when preparing and serving food to residents; and,-Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination. Findings include:I. Maintain safe holding temperatures for food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Time/temperature control for safety food cold holding shall be maintained at 5 degrees Celsius (C) (41 degrees Fahrenheit) or less.""Time/temperature control for safety food that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees C (135 degrees Fahrenheit) or above."According to the product guidelines for MedPass Fortified Nutritional Shake, retrieved on 6/11/24 from https://www.hormelhealthlabs.com/resources/for-healthcare-professionals/product-protocols/med-pass-fortified-nutritional-shake-medication-pass-program/, "MedPass products can safely remain on a medication cart as long as it is kept at refrigerated temperature range 34 to 40 degrees F."Cover, label and refrigerate opened containers of MedPass products and discard after four days as long as the product has been kept at the proper refrigerated temperature range. According to the product guidelines for ReadyCare Nutritional Drink, retrieved on 6/11/24 from https://lyonsreadycare.com/collections/unintended-weight-loss/products/vanilla-2-0,"Shelf Life: 9 (nine) months from date of manufacture. Refrigerate after opening and use within 72 hours."B. Facility policyThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part, "Cold foods are kept between 34 to 41 degrees Fahrenheit F before serving and frozen foods are kept at 0 degrees F or below. Hot foods are cooked to above 165 degrees F or per USDA (United States Department of Agriculture) Food Code and held at least 140 degrees F until service."C. ObservationsOn 6/3/24 at 5:04 p.m. initial temperatures were taken of food items that were to be served to residents during dinner service. A tuna melt sandwich, previously heated and meant to be served hot, had a temperature of 133.1 degrees F. Two trays of garden salad were checked for temperatures. One tray, which was sitting on ice on the serving line, had a temperature of 45.5 degrees F. The other tray, which was taken from the refrigerator, had a temperature of 48.9 degrees F. A slice of cheesecake had a temperature of 44.7 degrees F.On 6/4/24 temperatures of food items kept at the nurses' medication carts were obtained. Each medication cart had a small cooler with ice in it. The lid for the cooler on each cart was not able to be closed due to the height of the nutritional supplement bottles inside the coolers. At 1:20 p.m., on the Sagewood wing medication cart, the MedPass nutritional supplement measured 59 degrees F and the ReadyCare nutritional supplement measured 68 degrees F.-The temperatures of both nutritional supplements were above the safe temperature parameter for cold foods of 41 degrees F or less. At 1:27 p.m. on the Pinebrook wing medication cart, the ReadyCare nutritional supplement measured 62 degrees F.-The temperatures of the nutritional supplement was above the safe temperature parameter for cold foods of 41 degrees F or less. D. Staff interviewsThe nutrition services director (NSD) was interviewed on 6/3/24 at 5:04 p.m. The NSD said the ideal holding temperature for hot foods was 165 degrees F.The NSD was interviewed again on 6/4/24 at 1:20 p.m. The NSD said cold foods should stay under 41 degrees F and food items kept on the medication carts should be below 41 degrees F. The NSD said the kitchen staff had no involvement preparing or maintaining the medication carts' coolers. Registered nurse (RN) #1 was interviewed on 6/4/24 at 1:25 p.m. RN #1 said the facility nurses prepared the coolers for the medication carts at the start of each shift. RN #1 said the nurses did not have any thermometers at their station aside from the ones used to obtain vitals and she had not taken any temperatures of the food items kept on the medication carts. II. Ensure kitchen staff were wearing appropriate hair restraints while preparing and serving foodA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part: "Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. B. Facility policyThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part, "Staff always wear proper clothing and footwear, preferably uniforms, and hair restraints on."C. ObservationsOn 6/3/24 Cook (CK) #1 was observed during a continuous observation of the dinner service, beginning at 4:30 p.m. and ending at 6:25 p.m. CK #1 was preparing and serving food for residents throughout the observation period. -CK #1 had a goatee and mustache and he was not wearing a beard net throughout the observation period. D. InterviewsThe registered dietitian (RD) was interviewed on 6/4/24 at 2:05 p.m. The RD said kitchen staff members with facial hair should wear beard nets. The RD said CK #1 was normally clean-shaven and she had not noticed his facial hair was longer. III. Inappropriate handling of ready-to-eat foodsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."B. Facility policyThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions Policy, dated 1/2024, was provided by the NHA on 6/6/24 at 11:34 a.m. It read in pertinent part: "Bare hands do not touch ready to eat foods."C. ObservationsThe 6/3/24 dinner service was observed during a continuous observation, beginning at 4:30 p.m. and ending at 6:25 p.m. At several points throughout the observation period, CK #1 touched hamburger buns with his bare hands after handling tray cards and serving utensils. Additionally, CK #1 was observed using his bare hands to shift potato chips to the side of the plates to make room for the garden salad on several occasions.-At 5:45 p.m., dietary aide (DA) #1 was preparing sandwiches during the dinner service. DA #1, with bare hands, untied a bag of bread, pulled out two slices of bread with her hand, closed the bread bag and held the bread with her bare hands as she cut it with a knife. -DA #1 proceeded to place the bread, still with her bare hands, onto a plate. -DA #1 had been touching tray cards, a cart at the end of the tray line and serving utensils prior to touching the bread with her bare hands. At 6:25 p.m. DA #1 again took bread from the bread bag with her bare hands and placed it on a plate. DA #1 added egg salad, then placed another piece of bread on top of the sandwich with her bare hands. -Again, DA #1 had been touching tray cards, a cart at the end of the tray line, and serving utensils prior to touching the bread with her bare hands. D. Staff interviewThe RD was interviewed on 6/4/24 at 2:05 p.m. The RD said she had not seen staff handling ready-to-eat foods with their bare hands. The RD said ready-to-eat foods should be handled with tongs.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches);-Ensure housekeeping staff were trained appropriately on housekeeping procedures; and,-Ensure surface disinfectant dwell times (how long surfaces remained wet with disinfectant) were adhered to. Findings includeI. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 6/6/24 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, "High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/5/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."II. Facility policy and procedureThe Cleaning and Disinfection of Environmental Surfaces policy and procedure, revised August 2019, was received from the nursing home administrator (NHA) on 6/6/24 at 12:59 p.m. revealed in pertinent part "Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities. "Manufacturer's instructions will be followed for proper use of disinfecting products including: recommended use-dilution, material compatibility, storage, shelf-life, safe use and disposal."III. Disinfectants used in the facilityThe Victoria Bay TableTop Sanitizer product sheet, undated, was provided by the NHA on 6/6/24 at 12:59 p.m. It revealed in pertinent part, "Treated surfaces must remain wet for three minutes."The Victoria Bay Acid Free Disinfectant Restroom Cleaner product sheet, undated, was provided by the NHA on 6/6/24 at 12:59 p.m. It revealed in pertinent part, "Treated surfaces must remain wet for 10 minutes."IV. ObservationsDuring a continuous observation on 6/4/24, beginning at 8:55 a.m. and ending at 9:39 a.m., Housekeeper (HSK) #1 was observed cleaning room #121 (a shared resident room). HSK #1 sprayed the toilet and toilet riser with Victoria Bay Bathroom Disinfectant. HSK #1 waited 10 minutes then took a dry rag and wiped the toilet down, however the surface did not remain wet for 10 minutes. HSK#1 cleaned the bathroom in the following order: starting with the toilet bowl rim, the outside toilet pedestal to the floor, toilet seat, toilet lid, and lastly the water tank reservoir on the back of the toilet. HSK #1 wiped down the toilet riser starting with the toilet seat, toilet lid and then the handle bars.-HSK #1 failed to disinfect the toilet and toilet riser from the cleanest area to the dirtiest area.-HSK #1 failed to allow the toilet and toilet riser surfaces to remain wet for the recommended dwell time.-HSK #1 proceeded to wipe down the grab bars in the bathroom with the same rag used to clean the toilet. She did not spray the grab bars with the disinfectant prior to wiping them with the dirty rag. HSK #1 sprayed a new dry rag four times with Victoria Bay Tabletop Sanitizer. She wiped the entrance door handles, the door, bedside tables and dressers for both residents in room #121. The surfaces of the items remained wet for approximately 30 seconds.-HSK #1 failed to change rags between each resident's side of the room.-HSK #1 failed to spray the disinfectant on the surfaces and allow the surfaces to remain wet for the recommended dwell time.-HSK #1 failed to clean all high touch surfaces in the resident's room (see professional reference above). During a continuous observation on 6/4/24, beginning at 9:42 a.m. and ending at 10:04 a.m., HSK #1 was observed cleaning room #306 (a shared resident room). HSK #1 wiped down the bathroom in room #306 with a dry rag after spraying the bathroom with Victoria Bay Bathroom Disinfectant in the following order: beginning with the sink faucet handles, sink bowl, toilet riser handles, seat of the toilet riser, grab bars on the walls in the bathroom. HSK #1 then wiped down the toilet in the following order: beginning with the toilet bowl rim, toilet seat, toilet lid and water tank reservoir on the back of the toilet. HSK#1 wiped down the paper towel dispenser with the same rag she used to wipe the sink, toilet riser and toilet.-HSK #1 failed to allow the surfaces in the bathroom, including the toilet and toilet riser surfaces, to remain wet for the recommended dwell time.-HSK #1 failed to disinfect the bathroom from the cleanest area to the dirtiest area. At 9:45 a.m. HSK #1 sprayed a dry cloth with Victoria Bay Tabletop Sanitizer and proceeded to wipe the door handles, bedside tables, night stands and dressers for both residents in room #306. The surfaces of the items remained wet for approximately 15 seconds..-HSK #1 failed to change rags between each resident's side of the room.-HSK #1 failed to spray the disinfectant on the surfaces and allow the surfaces to remain wet for the recommended dwell time.-HSK #1 failed to clean all high touch surfaces in the resident's rooms (see professional reference above). V. Staff interviewsHSK #1 was interviewed on 6/4/24 at 10:05 a.m. HSK #1 said the Victoria Bay Tabletop Sanitizer had a two to three minute dwell time and the bathroom disinfectant had a 10 minute dwell time. HSK #1 said the surfaces did not need to remain wet the entire dwell time to be effective. HSK# 1 said she used only two rags to clean resident rooms, one for the bathroom and a second one for the residents' room. HSK #1 said the number of rags used did not change if the resident room was a single resident room or a shared resident room. HSK #1 identified door handles, dresser handles, toilets and grab bars as high touch surface areas which needed to be cleaned daily. HSK #1 said she forgot to clean the call lights, bed controls and light switches in room #121 and room #306. HSK #1 said she should have cleaned all high touch surfaces to help prevent infections. The housekeeping laundry manager (HLM) was interviewed on 6/5/24 at 1:07 p.m. HLM said the Victoria Bay Bathroom Disinfectant had a 10 minute dwell time and the Victoria Bay Tabletop Sanitizer had a two to three minute dwell time. The HLM said the Victoria Bay Bathroom Disinfectant had a 10 minute dwell time however most times it would dry before the 10 minutes was up. The HLM said the housekeepers should re-wet the surface to ensure that it stayed wet for the entire 10 minutes. The HLM said dwell times were important to follow to ensure the disinfectant properly disinfected the areas being cleaned for infection prevention. The HLM said the bathroom should be wiped down from the cleanest areas to the dirtiest to prevent moving bacteria from higher soiled areas to a less soiled area. The HLM said bathrooms should be wiped down in the following order: sink handles, sink bowl, light switch, towel racks, and toilet areas last. The HLM said the toilet should be wiped down in the following order: tank reservoir, toilet lid, toilet seat, toilet bowl rim and last the outside pedestal to the floor. The HLM said if the housekeepers were not wiping in the correct order they were contaminating the other areas in the bathroom. The HLM said the housekeepers should use at least two rags in the bathroom to ensure proper cleaning and disinfection. The HLM said high touch areas in resident rooms, such as the call lights, television remotes, bed controls, bedside tables and door knobs/handles, should be disinfected/cleaned daily.-The HLM said housekeepers could use the same rag for both residents in one room as long as they used different sides of the rag for bed A versus bed B. The HLM said she would like to complete audits on housekeepers for proper cleaning and disinfecting techniques at least monthly but she had not been able to complete those audits yet. The infection preventionist (IP) was interviewed on 6/6/24 at 10:40 a.m. The IP said he met with the HLM frequently about potential infections and to ensure correct soap/disinfectants were being used appropriately. The IP did not know the dwell time for the Victoria Bay Tabletop Sanitizer or bathroom disinfectant. The IP said if the manufacturer's recommendations said the surface needed to remain wet for a certain amount of time, the dwell time should be followed to ensure proper disinfection was completed. The IP identified the bedside tables, grab bars, bed rails, television remotes, bed controla, door handles and resident water cups as high touch surface areas in residents' rooms. The IP said when housekeepers were cleaning a bathroom they should clean it from the cleanest area to the dirtiest area to prevent moving bacteria/germs from the dirtier area to a cleaner area.

A complaint survey, prompted by #CO32242 and Incident #33860 was conducted on 11/1/23. No deficiencies were cited.