COLUMBINE MANOR CARE CENTER

The Colorado Department 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 a representation of the facility's general characteristics. The facility is one story wood framed Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The facility is existing and is licensed for 112 beds. This certification survey conducted on May 12, 2026 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiency is corrected. The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 45 residents on May 12, 2026

Through observation, interviews, and record review during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by: 1) Delayed-egress doors within the means of egress were sticking and requiring more than 15lbs of force to open. 7.2.1.4.5.1The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows: (1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the 6 affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation, interviews, and documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by: Paint on the escutcheons, which are part of the sprinkler head assembly. 5.2.1.1.2Any 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 manufacturerThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all 6 smoke compartments. Deficient items were discussed with the facility administrator and maintenance director during the exit conference.

Based on record review, interviews, and observation during the survey, it was determined that the facility failed to maintain all corridors. This was evidenced by the following:During the walk-through of the facility, it was found that the facility utilizes swamp coolers to provide cooling for the corridors and to provide cooling in resident rooms, which turns all the corridors into plenum spaces. Per NFPA 101, Section 9.2 it states that corridors cannot be used as a plenum space. This deficiency potentially affects all residents, staff and visitors in all 6 smoke compartments. The deficiency was discussed with the facility Administrator during the exit conference.

A recertification survey with Incident #2631392 was completed on 4/12/26 to 4/16/26. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/13/26 to 4/16/26. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure residents were treated with respect and dignity was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life in one of one dining rooms. Specifically, the facility failed to ensure the residents did not have to wait in a long line to place their meal orders prior to entering the dining room and being seated for meals. Findings include:I. Facility policy and procedureThe Resident Dining Services policy, revised 4/29/25, was provided by the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. The policy read in pertinent part, “The facility has an established process to ensure food is served in accordance with professional standards for food service and in a safe, clean, homelike environment. Dining services will include foods served timely and appropriate assistance provided to meet the individual needs of the residents to create a pleasant experience.“A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident.”II. ObservationsOn 4/13/26 at 11:55 a.m. the residents were lined up in the dining room hallway to place their meal orders with an unidentified dietary aide (DA) standing by a desk. Two residents were standing in the hallway without an assistive device, three residents were standing with their walkers, and several residents were seated in wheelchairs. The line went down to the main hallway by the kitchen entrance door and blocked the hallway. At 11:58 a.m. Resident #33 turned around his four-wheel walker and sat on it while waiting in line. On 4/14/26 at 5:27 p.m. the residents lined up in the dining room hallway to place their diner orders with an unidentified DA. The line wrapped outside into the main hallway by the dining room. During a continuous observation on 4/15/26, beginning at 11:40 a.m and ending at 12:20 p.m., the following was observed:At 11:40 a.m. several residents were lined up to enter the dining room to place their meal order prior to sitting down at a table. At 11:50 a.m. there were seven residents waiting in line with the line wrapping outside into the main hallway by the dining room. Resident #33 who was third in line was swaying and shaking his head. Resident #33 then turned his four wheel walker around and sat down on the seat the walker had built in to wait for his turn to give the unidentified dietary aide his lunch order. On 4/16/26 at 11:53 a.m. the residents lined up in the dining room hallway to place their meal orders with a DA. The line wrapped outside into the main hallway by the dining room. III. Resident interviewResident #33 was interviewed on 4/13/26 at 1:53 p.m. Resident #33 said he ate lunch in the dining room and dinner in his room. He said placing meal orders took longer when he had to wait in line. Resident #33 said wait times varied depending on what time he arrived at the dining room. He said he did not like waiting in line. IV. Additional interviewA frequent visitor was interviewed on 4/13/26 at 8:30 a.m. The frequent visitor said she had concerns regarding residents lining up in the dining room to place their meal orders, because they were having to wait in long lines. V. Staff interviewsDA #1 was interviewed on 4/16/26 at 9:58 a.m. DA #1 said the dietary aides or certified nurse aides (CNAs) assisted the residents who ate meals in their rooms with filling out meal order tickets the night before. He said residents who ate meals in the dining room placed their meal orders upon arrival in the dining room. DA #1 said the residents lined up and a DA assisted them with placing meal orders. He said the facility had used this meal ordering process for almost a year. DA #1 said he was unsure about the choice of ordering meals in the dining room, but the facility planned to change the process the following month so residents could complete their meal order tickets the night before. He said the change would, in his view, ease the meal process for both residents and kitchen staff. DA #1 said residents had not complained about the process. The dietary manager (DM) was interviewed on 4/16/26 at 10:18 a.m. The DM said the CNAs assisted the residents who ate meals in their rooms with completing the meal orders the night before. He said the residents who ate meals in the dining room placed their meal orders when they arrived in the dining room. The DM said the facility implemented the process of residents lining up because in the past residents entered the dining room and sat randomly at tables. He said it was hard for the DAs to determine which residents arrived first or later for meal service. The DM said residents had complained about arriving at the dining room first but being served last. He said the facility had used the process of residents lining up to place meal orders in the dining room for almost two years. He said there had been no identified safety hazard concerns associated with the process and residents had not complained about it. The DM said the facility intended to continue the process because it had been effective. The NHA was interviewed on 4/16/26 at 11:56 a.m. The NHA said the facility had not seen the residents lining up as a problem. She said the residents had not complained about it. The NHA said it had been a proper process where residents could connect among them and were excited about it. She said the DM informed her the frequent visitor had raised concerns regarding the process. The NHA said as long as the residents believed the process was still good for them, the facility would continue to follow residents’ preferences rather than the ombudsman's concerns. The NHA said she had not observed any negative consequences associated with residents lining up. The NHA returned at approximately 1:00 p.m. and clarified the frequent visitor had raised that concern to the DM one year ago.

Based on interviews and record review, the facility failed to ensure one (#59) of three sample residents received notification of changes in eligibility for Medicare or Medicaid covered services, what the resident’s financial responsibility may be, and their appeal rights. Specifically, the facility failed to ensure Resident #59 were provided with a Notice of Medicare Non-Coverage (NOMNC) when their skilled nursing benefits ended timely. Findings include:I. Facility policy and procedureThe Notice of Changes policy, revised on 4/1/26, was received from the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. It read in pertinent part, "Residents will be told when charges will occur to their bills. The facility will fully inform the resident of services and related charges. “The NOMNC form is given by the facility to all medicare beneficiaries at least two days before the end of a Medicare covered part A stay or when all of part B therapies are ending, The NOMNC informs beneficiaries of the right to expedite review by a quality improvement organization.”II. Resident #59 A. Resident statusResident #59, age greater than 65, was admitted on 1/2/26 and discharged on 2/9/26. According to the February 2026 computerized physician orders (CPO) diagnoses included fracture of the left femur (broken bone of the upper leg), Parkinson's disease (a neurodegenerative disorder impacting movement and function of the body), hypertension (high blood pressure) and dementia (cognitive decline affecting memory, communication and impaired reasoning). The 2/9/26 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for metal status (BIMS) score of 12 out of 15. The MDS assessment documented Resident #59 was a planned discharge to home/community. B. Record reviewThe NOMNC for Resident #59 identified services were to end on 2/9/26. Resident #59 signed the NOMNC on 2/9/26. It also documented the resident was deciding to leave prior to the two day notice. -However, the facility failed to provide the resident two day notice of end of coverage on 2/9/26. A nursing behavior progress note, dated 1/28/26 at 9:47 p.m., documented Resident #59 was upset and argumentative while the nurse was on the phone with the resident's family member. Resident #59 was saying that the wife needed to come pick him up and that he was being discharged. The nurse spoke with the family member and explained that discharge planning would include her and required physician’s orders and appropriate paperwork and the facility would contact her when plans were finalized. The family member stated this was the usual communication style of the resident. The nurse provided reassurance to the resident about safety and that discharge would not occur without appropriate planning and communication. Resident #59 was redirected and accepted reassurance and returned to bed. Resident #59 was resting comfortably in bed with no further agitation. -However, the facility failed to issue the NOMNC timely, despite the resident’s plan to discharge. A plan of care note, dated 2/4/26 at 5:55 p.m., documented a referral for home health was declined by the resident and family. -However, despite the facility being aware of the resident’s upcoming discharge, the facility failed to issue the NOMNc timely. A late entry care management note, dated 2/9/26 at 9:34 a.m., documented the resident elected to discharge home and continued to have skilled nursing days available. Review of Resident #59’s electronic medical record (EMR) did not reveal any physician’s notes documenting the resident was requesting to discharge the facility prior to the 2/9/26 discharge. The discharge care plan, dated 1/2/26, revealed Resident #59 had a discharge plan and wished to return to the community. III. Staff interviewsThe social service director (SSD) and the admission coordinator were interviewed on 4/16/26 at 9:24 a.m. The SSD said once they received notification a resident’s services would be ending they provided the resident with notification. The SSD said the notification was to allow 48 hours prior to end of services so the resident could appeal the decision if they feel they needed to remain on services longer. The SSD said she assisted the resident if needed to appeal the decision. The SSD said a resident may choose to leave prior to the last covered date if they choose too. The admission coordinator said at the time of Resident #59’s discharge, she was holding double duty assisting with admissions and discharges. The admission coordinator said the administrator at the time had instructed them to give all residents a NOMNC regardless of their status at time of discharge. The admission coordinator said she was not the staff member who issued the NOMNC to Resident #59 on 2/9/26. The SSD said Resident #59 did not receive his notice timely in order to provide him 48 hours notice. The NHA joined the interview at 9:35 a.m. She said the facility had been working on improving the process for issuing the NOMNCs. The NHA said it was identified prior to the survey, but the facility had not created a performance improvement plan at that time. The NHA said she would create a performance improvement plan for NOMNC after the interview. IV. Facility follow upOn 4/16/26 at 3:52 p.m. after survey exit the facility provided a copy of the performance improvement plan, undated, for failure to properly issue and /or manage the NOMNC process in accordance with medicare requirements. On 4/17/26 at 9:59 a.m the NHA provided an attestation from Resident #59 physicians dated 4/16/26. It indicated throughout the residents' stay he made notable and frequent requests for discharge despite his ongoing disability. After several weeks of Resident #59’s behavior, the facility finally arranged for discharge home with home health, despite his preference to remain in the facility longer. The wife picked up the resident on 2/9/26 at discharge. -There were no physician’s notes indicating the physician had conversation with Resident #59 or family about residents wanting to leave prior to the 2/9/26 discharge (see record review above).

A complaint survey, prompted by #CO38563 was conducted on 12/30/24 to 12/31/24. No deficiencies were cited.

A complaint survey, prompted by #CO37855 and Incident #37839 was conducted 10/22/24. No deficiencies were cited.

A complaint survey, prompted by #CO36829 was conducted on 8/14/2024. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 1/9/24 for all previous deficiencies cited on 10/12/23. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on November 2, 2023 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, Type II (111) construction with no basement. The original facility was constructed in 1973 and an addition added in 1985. The facility is licensed for 112 beds. This facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler systems. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Administrator and Maintenance Director during the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. One motion locks need to be installed on doors E-9, E-10, E-7, E-8 , E-5, E3, Bath by E-2 (Where new handles were installed throughout facility)NFPA 101 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101. 1. Emergency Lights 30 sec reports | 12 months of inspection reports not available| only July - Oct 232. Exit Lights 30 sec reports | 12 months of inspection reports not available| only July - Oct 23NFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1)Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.1. Storage no self closer's rooms E-9, E6, E4 | Areas storing large amount of combustible material19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.19.3.2.1.3 The doors shall be self-closing or automatic-closing. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the facility. Deficient items were discussed with the Administrator and Maintenance director 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. Stove needs wheel blocks for returning to original position after cleaningNFPA 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 has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director 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 Section 9.6 and NFPA 72.1. Fire Alarm No Annual report available for review during survey 2. Fire Alarm No Semi-annual report available for review during surveyNFPA 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. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. Doors do not resist the passage of smoke E-6 (knob missing), bed blocking door, Door E-4, blocked from closingNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 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 and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:1. Gas orifice on dryer rated for 0-2000 feet in elevation in the laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. 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 this area of the smoke compartment facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 1051. Fire Damper (4yrs) | No report available for review during surveyNFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills non compliant | not completed once per quarter per shiftNFPA 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 has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and record review the facility did not maintain smoke policy in accordance with NFPA 101. 1. Smoking policy need to identify no smoking around oxygen 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 other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. 5. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. 6. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were identified during the survey and discussed with the Administrator and at the exit conference.

Based on 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:1. 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 has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen transfer room Ventilation fan not working Oxygen storage not separated empty and fullNFPA 99: 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 or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the facility. Deficient items were identified during the survey and discussed with the Administrator and at the exit conference.

A recertification survey with Incident #31723 was completed on 10/9/23 to 10/12/23. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/9/23 to 10/12/23. No deficiencies were cited.

Based on record review and staff interviews, the facility failed to ensure four (#44, #103, #203 and #47) of seven out of 28 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Clarify physician's orders and obtain dose information prior to administration of topical skin medication for Residents #44, #103 and #203;-Hold Digoxin (to treat heart failure) when Resident #47's heart rate was below 60; and, -Ensure consents and black box warnings were in place for the use of antidepressants before administration for Resident #47. Findings include: I. Topical skin medication ordersA. Professional referenceThe Voltaren (Diclofenac) gel drug information was accessed on 10/11/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. "Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that could be prescribed in intravenous, oral, topical, and ophthalmic formulations. "The use of analgesic and antipyretic properties increases the risk of serious gastro-intestinal events and may increase serious cardiovascular events; use the lowest dose of the shortest time. "The topical dosage of diclofenac gel is prescribed as four grams (four and one half inches) topically four times a daily, with a maximum of 16 grams a day per lower extremity joint) and/or two grams (two and one fourth inches) topically four times daily per upper extremity joint. Do not exceed a total dose of 32 grams over all affected joints." B. Facility policyThe Medication Administration policy, dated 8/24/23, was received by the nursing home administrator (NHA) on 10/16/23. The policy stated in pertinent part:"Staff who are responsible for medication administration will adhere to the Rights of Medication Administration;"Right dose. Check the medication administration record and the doctor's order before medication. Use standard measuring devices such as syringes, graduated cups, or scaled droppers."If there is any doubt about the dose on the medication administration, required considerations including the purpose, diagnosis or indication for use is required for administration of medication."A physician order that includes dosage, route, frequency, duration, and other record or if there is a question on the drug, stop and verify all information before administering."C. Record reviewResident #44 had a physician order Voltaren gel one percent. The order directed the medication to be applied every 12 hours as needed for pain and failed to include a dose. The resident received the medication on 10/9/23 and 10/10/23. Resident #103 had a physician order for Diclofenac gel one percent. The order directed the medication to be applied every eight hours as needed for pain and failed to include a dose. The resident received the medication on 10/1/23, 10/2/23 and 10/3/23. Resident #203 had a physician order for Voltaren gel one percent. The order directed the medication to be applied every 12 hours as needed for pain and failed to include a dose. The resident received the medication on 10/10/23. D. InterviewsRegistered nurse (RN) #1 was interviewed on 10/11/23 at 3:03 p.m. She said she was aware Voltaren gel was a medication that required a measured dose. She said if a medication order was missing a dose the nurse should contact the physician to clarify the order. The RN said Voltaren gel was received packaged from the manufacturer with a dose guide for accurate measurement. The director of nursing (DON) was interviewed on 10/11/23 at 3:20 p.m. She said every medication order was expected to include a dose as prescribed by the physician. The DON said if a medication dose was missing the nurse was to contact the physician and clarify the medication order prior to medication administration. The DON said was she was unaware the three medication orders for Resident #44, #103 and #203 were missing dose information. E. Facility follow-upOn 10/11/23 at 3:55 p.m., the DON completed a record audit of physician's orders for Voltaren gel. She clarified physician's orders and obtained dose information for Volaren gel for Residents #44, #103 and #203. II. Resident #47A. Resident statusResident #47, age above 65, was admitted on 7/10/23. According to the October 2023 CPO, the diagnoses included chronic atrial fibrillation and anxiety disorders. The 7/12/23 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She had no behaviors and did not reject care. All her activities of daily living only occurred once or twice. She used oxygen and received antidepressants daily. B. Record reviewThe October 2023 CPO documented Resident #47 was ordered:-Lexapro (antidepressant) 15 mg (milligrams) by mouth one time a day for depression;-Cymbalta (antidepressant) 60 mg by mouth at bedtime for depression: and -Digoxin 125 mcg (micrograms) one time a day on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday. The digoxin was administered on 9/23/23. Her heart rate was 58. The digoxin was administered a second time on 9/27/23. Her heart rate was 57. There were no consents and black box warnings for the two antidepressants administered daily. Care PlansThe antidepressant medication care plan, initiated 7/15/23. It documented the resident used the antidepressant medication for depression. The interventions included educating resident/family/caregivers about risks, benefits and the side effects and /or toxic symptoms. There was no care plan in place related to the use of digoxin. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/12/23 at 10:08 a.m. She said consents should be signed for antidepressants before administration of the medication. She said the consent consisted of potential side effects and special attention for a resident with heart disease. She said it was important for the consents to be signed so the resident/family would be aware of the risks of taking the medication. She said Digoxin should never be given if the resident's heart rate was below 60. She said it could cause low heart rate and Digoxin toxicity. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said consents should be signed before administering an antidepressant. She said the resident/family should be aware of possible side effects and adverse reactions. She said Digoxin should not be given if a resident's heart rate was below 60. She said parameters should have been put into place to always check the resident's heart rate before administering Digoxin. She said if the heart rate was below 60 and the resident was given the medication, it could drop the heart rate even lower and cause an adverse event. The regional director of clinical services (RDCS) was interviewed on 10/12/23 at 3:59 p.m. She said the social worker was not aware that she was responsible for getting consents signed. She said the facility had completed an audit to make sure all consents for psychotropic medications were in place.

Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#105) out of 10 residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #105 was assessed by a registered nurse (RN) after a fall. Findings include:I. Resident statusResident #105, age above 65, was admitted on 11/23/22 and discharged 4/22/23. According to the April 2023 computerized physician orders (CPO), the diagnoses included vascular dementia, weakness, unsteadiness on feet, difficulty in walking, non-traumatic acute subdural hemorrhage (brain bleed), lack of coordination and muscle weakness. The 4/14/23 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. He had physical and verbal behavioral symptoms directed towards others as well as other behavioral symptoms not directed at others, which put the resident at significant risk for physical illness or injury. He wandered daily. He had a worsening in his behavior. He required extensive assistance with bed mobility, transfers and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. He used a wheelchair. The resident had two or more falls since admission with injury and one with major injury. II. Record reviewThe fall care plan, initiated 11/23/22 and revised 5/1/23, documented the resident was at risk for falls related to a history of falls and dementia. The goal was for the resident not to sustain serious injury requiring hospitalization. According to a progress note dated 3/9/23 at 1:30 p.m. the housekeeping staff witnessed Resident #105 fall in his room and get himself up off of the floor. The note was written by a licensed practical nurse (LPN). According to a progress note dated 3/16/23 at 12:47 p.m. Resident #105 was found on the floor by ancillary staff near his bed. The resident's head and neck areas were intact. His grip strength was equal to both sides and his range of motion was within normal limits. The note was written by a LPN. According to a progress note dated 3/25/23 at 11:34 a.m. a certified nurse aide (CNA) witnessed Resident #105 fall in his room next to his bed. The resident's head and neck areas were assessed and intact. His grip strength was equal to both sides and his range of motion was within normal limits. The note was written by a LPN. According to a progress note dated 4/7/23 at 1:11 p.m. Resident #105's roommate witnessed him fall out of bed while trying to ambulate on his own. The note was written by a LPN.-The note did not include an assessment for injuries. According to a progress note dated 4/16/23 at 12:24 a.m. the nurse was called to Resident #105's room and found him lying on the right side of the floor in the doorway to his room. The resident was noted to have a skin tear to his right forehead above his eyebrow, skin tear to his right hand second knuckle, and a skin tear to his right elbow. Neurological checks were initiated and upper and lower extremity strength were equal. The note was written by a LPN.According to a progress note dated 4/17/23 at 9:15 p.m. Resident #105 passed out and fell out of his wheelchair onto the lobby floor. Blood was noted in his catheter and vomit coming from his mouth. He had a skin tear to his left elbow. The note was written by a LPN.-A full review of the residents medical record was conducted on 10/11/23. The medical record did not reveal documentation of the resident being assessed by a RN after each of the above falls. III. Staff InterviewsCertified nurse aide (CNA) #1 was interviewed on 10/12/23 at 10:01 a.m. She said if a resident had a fall, the CNA would report it to the nurse and start neurological checks on the resident. She said Resident #105 had many falls and was impulsive. RN #1 was interviewed on 10/12/23 at 10:08 a.m. She said an RN should assess a resident, no later than two hours,after a fall. She said after each fall, a resident should have interventions in place to prevent further falls. She said Resident #105 had many falls and interventions were put into place after every fall. She said she was not sure why an RN did not assess him for injury after each fall. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said licensed practical nurses could not assess residents after a fall, because it was not in their scope of practice. She said a RN was required to assess a resident for injuries after a fall.

Based on observations, record review and interviews, the facility failed to ensure two (#17 and #47) of 10 residents who required respiratory care received the care consistent with professional standards of practice out of 28 sample residents. Specifically, the facility failed to:-Ensure a physician's order was in place for the use of oxygen for Resident #17; and, -Ensure Resident #17 and Resident #47 received oxygen therapy as ordered. Findings include:I. Facility policyThe Oxygen Administration policy, last revised 8/2/21, was provided by the nursing home administrator (NHA) on 10/11/23 at 2:31 p.m. It read in pertinent part:"Oxygen will be administered in accordance with physician orders and current standards of practice. All facility staff will be educated on oxygen administration, safety, and storage upon hire, annually, and as indicated thereafter."Oxygen administration helps relieve hypoxemia (low oxygen levels)and maintains adequate oxygenation of tissues and vital organs. "Verify the practitioner's order for oxygen therapy because oxygen is considered a medication or therapy and requires a prescription."II. Resident #17A. Resident statusResident #17, age above 65, was admitted on 1/27/2020 and readmitted on 7/12/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), chronic atrial fibrillation (irregular heart beat), congestive heart failure, essential hypertension (high blood pressure) and dependence on supplemental oxygen. The 7/14/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 11 out of 15. He had no behaviors and did not reject. He required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. Supervision with transfer and eating. He used oxygen. B. ObservationsResident #17 was observed on 10/9/23 at 11:21 a.m. laying in bed wearing an oxygen nasal cannula. The oxygen concentrator flow rate was set at 3.5LPM (liters per minute). Resident #17 was observed on 10/10/23 at 9:34 a.m. asleep in his wheelchair at the end of the hall. The portable oxygen flow rate was set at 4 LPM.Resident #17 was observed on 10/11/23 at 2:02 p.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM.Resident #17 was observed on 10/12/23 at 8:56 a.m. in the dining room eating breakfast. The portable oxygen flow rate was set at 4 LPM.C. Record reviewThe resident's CPO was reviewed on 10/9/23 at 11:21 a.m. and revealed the resident did not have a physician's order for oxygen therapy. -A physician's order was obtained for the oxygen on 10/9/23 at 5:15 p.m. The order was for oxygen at 3 LPM continuously via nasal cannula. The Emphysema/COPD care plan initiated on 7/15/23 included oxygen as ordered. -The care plan failed to include the amount of oxygen to administer and the route (nasal cannula/mask. III. Resident #47A. Resident statusResident #47, age above 65, was admitted on 7/10/23. According to the October 2023 CPO, the diagnoses included COPD, tobacco use, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. The 7/12/23 MDS assessment revealed, the resident was cognitively intact with a BIMS of 15 out of 15. She had no behaviors and did not reject care. All her activities of daily living only occurred once or twice. She used oxygen. B. ObservationsResident #47 was observed on 10/9/23 at 9:35 a.m. laying in bed wearing an oxygen nasal cannula. The oxygen concentrator flow rate was set at 3.5 LPM.Resident #47 was observed on 10/10/23 at 9:29 a.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM.Resident #47 was observed on 10/12/23 at 8:55 a.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM.C. Record reviewA physician's order dated 8/29/23 revealed the resident was ordered oxygen at 2 LPM continuously per nasal cannula. The Emphysema/COPD careplan was initiated on 7/15/23. The interventions included oxygen as ordered. -The care plan failed to include the amount of oxygen to administer and the route (nasal cannual/mask). D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 10/12/23 at 10:01 a.m. The CNA said the nurses let the CNAs know how many liters of oxygen a resident was on. Registered nurse (RN) #1 was interviewed on 10/12/23 at 10:08 a.m. She said the nurse received oxygen orders from the physician to include the amount of oxygen to administer and the route. She said a physicians order should have been in place before Resident #17 was placed on oxygen on 7/15/23. She said the resident should have been at 4 LPM at all times. She said she was not sure why he was at 3.5 LPM. -However, the resident's oxygen order required 3LPM (see order above). She said Resident #47's oxygen should have been set at 2 LPM. She said she was not sure why it was set at 3.5LPM. She said too much oxygen was not good for residents with COPD since it could lead to oxygen toxicity very quickly. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said a physician's order should be in place before administering oxygen to a resident since it was considered a medication. She said the nurse should have followed the physician's orders for the amount of oxygen to be administered. She said a resident with COPD could have negative effects on the brain and respiratory distress if given too much oxygen.

Based on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner. Specifically, the facility failed to:-Ensure potentially hazardous foods were monitored, held and cooled at appropriate temperatures; and,-Ensure dish room sanitation was maintained and dish room walls were a smooth cleanable surface. Findings include:I. Potentially hazardous foods monitored, held and cooled at appropriate temperaturesA. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "The person in charge shall ensure that: Employees are properly maintaining the temperatures of time and temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures; employees are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within four hours, through daily oversight of the employees' routine monitoring of food temperatures during cooling."Cooked time and temperature control for safety food shall be cooled within two hours from 135 degrees fahrenheit to 70 degrees fahrenheit and within a total of six hours from 135 degrees fahrenheit to 41 degrees fahrenheit or less. Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 135 degrees fahrenheit or above, or at 41 degrees fahrenheit or less. Time and temperature control for safety food includes cut leafy greens."B. Facility policy and procedureThe Keeping Hot Food Hot and Cold Food Cold inservice, undated, was provided by the nursing home administrator (NHA) on 10/12/23 at 10:28 a.m. It revealed in pertinent part, "Not only is it important for us to keep food safe during delivery, storage and preparation but we must also ensure that standard practices are followed during the holding of hot and cold food items. Bacteria grow at a much higher rate at room temperature. Therefore, we should keep hot food hot and cold food cold. Ensure that cold items placed in the dining rooms but not immediately served to the residents are held at 40 degrees fahrenheit or lower."C. Observations and record reviewOn 10/11/23 at 11:02 a.m. the following items were observed in the walk-in refrigerator:-A full size two inch deep steam table pan on the bottom shelf of the walk in refrigerator. The pan was covered with aluminum foil and written on the foil in black marker was "pot roast for lunch 10/10/23." -A six inch deep third size steam table pan with cooked sausage patties in liquid and covered with clear plastic wrap. The date 10/11/23 was written with black marker on the plastic wrap covering the pan.-A six inch deep sixth size steam table pan was observed with cooked, ground sausage and covered with clear plastic wrap. The date 10/11/23 was written with black marker on the plastic wrap covering the pan. On 10/11/23 at the following observations were made during lunch service in the dining room:-At 11:44 a.m. three full size baking sheet pans containing individually sliced and plated lemon meringue pies were on a baking rack in the dining room. Throughout service, the individually sliced pie pieces were held at room temperature and served to residents in the dining room or covered with foil and placed on resident room trays to be delivered. -At 11:45 a.m. battered fish was placed in the hot food holding steam table. Cook (CK) #1 took the internal temperature of the battered fish and the temperature was 162 degrees fahrenheit.-At 12:35 p.m. CK #1 lifted the top lid on half size deli refrigerator, reached into the pan of sliced lettuce and placed the sliced lettuce on a hamburger. The hamburger was then served to a resident.-At 12:38 p.m. a full size baking sheet pan of individually sliced and plated lemon meringue pies was still on the baking rack in the dining room. Room tray carts for two resident halls remained in the dining room with a total of 13 room trays not yet assembled including dessert.-At 12:46 p.m. eight pieces of battered fish were still in the hot holding steam table. A digital food thermometer was inserted into two different pieces of the battered fish and the internal temperature of the fish was 124 and 127 degrees fahrenheit. CK #1 said she would put a lid on top of the battered fish, and placed a metal lid over the pan that contained the battered fish. CK #1 then continued to serve resident meals.-At 12:57 p.m. a slice of lemon meringue pie was removed from the baking rack. A digital food thermometer was inserted into the piece of lemon meringue pie and the temperature was 50.6 degrees fahrenheit. The pie was placed on a test tray, and at 1:07 p.m. the temperature of the same piece of pie was 54 degrees fahrenheit. On 10/11/23 at 2:29 p.m. the box of lemon meringue pie revealed the lemon meringue pie was made with egg white, a time and temperature controlled for safety ingredient. The label on the lemon meringue pie container revealed the pie was to be stored frozen, served chilled, and not held at room temperature. -The lemon meringue pie served at lunch on 10/11/23 was held at room temperature for the duration of lunch service, the temperature of the pie was not monitored during service and the pie served reached a temperature above 40 degrees fahrenheit.-The temperature of the cut lettuce served at lunch was not monitored before or after lunch service. The temperature of the fish dropped below 135 degrees fahrenheit, the temperature of the fish was not monitored or held at the appropriate hot temperature. D. Record reviewFood temperature logs dated 8/28/23 to 10/12/23 were reviewed on 10/12/23. The food temperature log documented, "Cold foods should be at 40 degrees fahrenheit or below and hot foods should be at 140 to 170 degrees fahrenheit. Temperatures are recorded before food is served. If food temperatures are not within these ranges, corrective action must be taken before food is served to residents. Record the temperature of all hot and cold foods." -Food temperature cooling logs were requested but were not provided. Cooling temperature logs were not used to monitor and record cooling temperatures and times for the roast beef, sausage patties and ground sausage in the walk in refrigerator.-The initial temperature of the lemon meringue pie and sliced lettuce served on 10/11/23 was not recorded on the temperature log. The temperature log did not have a column for recording temperatures of food at the end of the meal to verify foods were held correctly. E. Staff interviewsCK #1 was interviewed on 10/11/23 at 12:05 p.m. CK #1 said she had not taken the temperature of the lemon meringue pie. She said the dietary staff removed the cold food out of the walk in refrigerator and took the temperature of foods served at the end of meal service but did not write the temperatures down. CK #1 was interviewed on 10/11/23 at 1:00 p.m. CK #1 said if the hot holding temperatures were too cold on food held in the steam table she would ask for more food to be cooked in the kitchen and brought to her. She would then serve the hot food instead of the food that was below the correct temperature. CK #1 said she did not know the temperature of the sliced lettuce had to be monitored. CK #1 and CK #2 were interviewed on 10/11/12 at 2:20 p.m. CK #1 and CK #2 said to cool the cooked food, the food was set on the table in the kitchen while other tasks were completed. CK #1 and CK #2 said the time and temperature of the leftover cooked foods was not monitored or recorded on a log before putting the leftover food in the walk in refrigerator. CK #1 and CK #2 said they did not know the temperatures of potentially hazardous cooked foods had to be monitored. CK #1 said she used the leftover sausage from breakfast to make ground sausage for the next breakfast meal for residents on mechanical soft diets. The nutrition services manager (NSD) was interviewed on 10/12/23 at 10:00 a.m. The NSD said the dietary staff have to monitor food holding temperatures. He said staff made him aware if food in the steam table was not at the correct holding temperature during meal service and the dietary staff made new food quickly. The NSD said he did not think the dietary staff took a beginning and end food temperature at every meal and he did not think the staff knew monitoring holding temperatures was required. The NSD said the dietary department did not reuse and reheat a lot of food leftover food.-However, the facility did have leftovers (see observations above). II. Dish room cleanliness and maintenance A. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude (prevent) accumulation of soil residues."B. ObservationsOn 10/9/23 at 9:25 a.m. the dish room was observed. Multiple dried food spots and debris were on the wall tile under the dish machine table. Dried food splatters were on the ledge of the dish machine table. The corner of the floor in the dish room had sticky black build up. The dish room entrance and walls inside the dish room consisted of ceramic tile, with multiple tiles missing from the wall inside the dish room and at the entrance to the dish room. Four coving (curved tile at the wall and floor juncture) tiles were missing under the dish machine table. A piece of fiberglass reinforced polymer wall section was placed in front of a section of wall tile under the dish machine. The fiberglass reinforced polymer wall section was not flush with the tile, but covered some of the tiles and the bottom and side edges of the fiberglass reinforced polymer wall section were not sealed. On 10/11/23 at 11:11 a.m. the dish room was observed. Multiple dried food spots and debris were on the wall tile under the dish machine table. Dried food splatters were on the ledge of the dish machine table. The corner of the floor in the dish room had sticky black build up. Four tiles were missing from the wall inside the dish room next to the dish machine leaving the wall underneath exposed that was porous with small holes. Eight tiles were missing from the wall to the dish room entrance leaving the material behind the tiles exposed with what appeared to be dried glue or adhesive. Four coving (curved tile at the wall and floor juncture) tiles were missing under the dish machine table. One piece of coving tile was leaning against another coving tile instead of being sealed to the wall. A piece of fiberglass reinforced polymer wall section was placed in front of a section of wall tile under the dish machine. The fiberglass reinforced polymer wall section was not flush with the tile, but covered some of the tiles and the bottom and side edges of the fiberglass reinforced polymer wall section were not sealed. The bottom of the fiberglass reinforced polymer wall section was in front of the coving tile instead of flush with the top edge the coving tile and sealed. C. Record reviewThe Daily Nutrition Services Cleaning Schedule was provided by the NSD on 10/12/23 at 10:30 a.m. The cleaning scheduled included to wipe down dish room counters but did not include to wipe down the dish room walls. D. Staff interviewsThe registered dietitian (RD) was interviewed on 10/11/23 at 11:15 a.m. She said the dish room was going to be remodeled. The environmental services director (ES) was interviewed on 10/11/23 at 1:15 p.m. The ES said he had reached out locally to get some vendors to fix the dish room tile and floor and possibly fix the grout in the dish room floor but had difficulty getting a return call from the vendors. He said he did not have any quotes yet for the items that needed repair in the dish room. The NSD was interviewed on 10/12/23 at 10:00 a.m. He said the corporate vice president (CVP) called a vendor who was scheduled to come the following week to the facility and fix the tiles in the dish room. The NSD said the cleaning task for the dish room was on the evening dishwashing position task sheet and/or the staff working the position knew what they should be doing. The NSD said he was unsure why the dish room cleaning was not being completed.

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. Specifically, the facility failed to:-Ensure the facility had a way to test water for the growth of Legionella by using expired Legionella test kits;-Ensure staff properly disposed of personal protective equipment (PPE) when the facility had an outbreak of COVID-19; and,-Ensure staff properly maintained respiratory supplies by failing to change oxygen cannulas weekly for two residents when the facility had an outbreak of COVID-19. Cross-reference F882 infection preventionist qualificationsFindings include:I. Facility policyThe Infection Prevention and Control program and plan, dated 5/19/23, was received 10/11/23 by the infection preventionist (IP) and read in pertinent part,"The facility has an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible."The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections."General procedures. Assign one or more individuals with training in infection control to provide on-site management of the infection control program."The facility administration and infection preventionist should ensure that current infections control standards of practice are based on recognized guidelines and facility assessment."The facility has established/implemented a surveillance plan, based on a facility assessment, for identifying, tracking, monitoring, and/or reporting of infections, communicable disease and outbreaks."The program includes early detections, management of a potentially infections, symptomatic resident that requires laboratory testing and/or the implementation of appropriate personal protective equipment (PPE)."Ensure staff follow the infection control plan standards, policies, and procedures (appropriate use of PPE)." II. Water testing failureA. Manufacturer package insert informationThe manufacture website for Lovibond water testing kits was accessed on 10/12/23 at https://www.lovibond.com/usa-en/water-testing/support-service/download-center. The manufacture package insert read, "test kits expired 18 months from the date of manufacture and all test kits were marked with a printed expiry date."B. Facility plan The Water Management Plan, dated 9/22/23, was received on 10/10/23 by the nursing home administrator (NHA). -The plan failed to include a schedule to test the facility water for Legionella. C. Record reviewOn 10/12/23 the environmental services director (ESD) provided copies of Legionella testing he completed on 8/8/23, 9/1/23 and 10/1/23, which showed the facility water was negative for Legionella. -However, the test kits used were Lovibond rapid test for Legionella pneumonia and were marked with expiration date of August 2022. . C. Staff interviews The ESD was interviewed on 10/12/23 at 12:10 p.m. He said the Legionella test kits had expired on August 2022. He said he was unaware he used an expired test kit and an expired test kit could lead to an inaccurate test result. The ESD was unable to locate an unexpired test kit on 10/12/23 to complete an immediate water test for Legionella. The NHA was interviewed on 10/12/23 at 12:25. He said he was unaware water testing was completed with expired test kits. He said testing for Legionella in the facility water supply was necessary so that the facility could intervene to prevent illness. D. Facility follow-upOn 10/12/23 at 3:15 p.m., theESD said he ordered new testing kits for Legionella and will complete testing when the kits were delivered. II. PPE disposal failureA. Professional referenceThe Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/8/23, retrieved on 10/22/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r2 read in pertinent part, "HCP (health care provider) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy." B. Observation On 10/12/22 at 11:45 a.m. a lunch tray for the resident in the room was placed on the top of the PPE set of drawers and the top drawer with clean PPE supplies was left opened. A used PPE gown was draped across the top of the set of drawers and had direct contact with the resident's lunch tray, items on the tray, the top surfaces of the drawers and the clean PPE items inside the opened top drawer. C. Staff interviewsThe director of nurses (DON) was interviewed on 10/12/23 at 11:49 a.m. She observed the used PPE gown draped across the clean surfaces and said the used PPE should be placed in a trash bin designated for used PPE and not placed on top of the clean PPE distribution area. Certified nurse aide (CNA) #3 was interviewed on 10/12/23 at 11:57 a.m. She said she had the PPE gown on and was prepared to enter the resident's room but was interrupted. She said she removed the gown and placed it on the PPE set of drawers. She said since she had not entered the resident's room, the gown was clean. The CNA said that she had worked on the hallway and had provided care for other residents and said her dirty clothing contaminated the PPE gown. The CNA said she had received education and training from the infectionist preventionist (IP) but had not seen the IP for several weeks. III. Respiratory equipment A. Facility policy The Oxygen Administration/Safety/Storage/Maintenance policy, dated 5/24/23, was received by the NHA on 10/10/23. The policy read in pertinent part, "Infection Control: change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out." B. Observation On 10/12/23 at 11:27 a.m., the nasal cannula oxygen tubing for two residents (#40 and # 8) was observed labeled 9/8/23. Both oxygen concentrators had a plastic zip lock bag taped to the concentrator to hold the cannula when not in use. Each bag was labeled 10/10/23. C. Staff interviews CNA #2 was interviewed on 10/12/23 at 11:39 a.m. He said the facility policy was for the CNA to change oxygen cannulas and tubing every Sunday. He said a new oxygen tubing should be labeled with the date the equipment was provided to the resident. The CNA said the date was used to verify equipment was changed. The NHA was interviewed on 10/12/23 at 12:35 p.m. He said CNAs were assigned the task to change the oxygen tubing and equipment weekly and he was unaware the oxygen cannulas had not been replaced weekly as required. He said the staff member that attached the new zip lock plastic bag to the oxygen concentrator failed to provide the resident with a clean oxygen cannula and tubing. The NHA acknowledged using old respiratory tubing could contribute to respiratory illness. D. Facility follow-upOn 10/12/23 at 3:22 p.m., the DON said Resident #40 and #8 were provided clean oxygen supplies.

Based on record review and interview, the facility failed to designate an interim infection preventionist (IP) that completed specialized training in infection prevention and control. Specifically, the full-time IP was on leave from the facility from 9/13/23 to 9/29/23 and 10/4/23 to 10/9/23. On 9/13/23 a resident tested positive for COVID-19, which led to a facility outbreak of COVID-19. From 9/13/23 to 10/2/23, twenty residents tested positive for COVID-19. The interim IP had not completed the education and training requirement prior to assuming the duties of the position. Findings include:I. Facility policyThe Infection Prevention policy, dated 5/19/23, was received by the IP on 10/11/23 at 10:23 a.m. The policy documented in pertinent part,"Our facility has an infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible."The facility has systems for the prevention, identification, reporting, investigation and control of infection and communicable diseases of residents, staff, and visitors. The system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections."General procedures. Assign one or more individuals with training in infection control to provide on-site management of the infection control program. The individual designated will meet the qualification requirements outlined in F882."II. Record reviewOn 10/11/23 the full-time IP provided documentation she completed specialized training for infection prevention on 3/19/23 and she was hired 2/23 as the facility ' s IP. -However, the IP was on 9/13/23 to 9/29/23 and 10/4/23 to 10/9/23 during the time there was a COVID-19 outbreak. The director of nursing (DON), who was interim infection preventionist, was unable to provide documentation she completed specialized training for infection prevention. Cross-reference F880 for failures with infection control. III. InterviewsThe IP and DON were interviewed together on 10/11/23 at 10:23 a.m. The IP said she received her IP certificate for completed training on 3/19/23 and was a registered nurse. She said she worked full-time in the facility except for the dates of her leave. The IP said requirements for IP included primary professional training in nursing, work at least part-time for the facility and have completed specialized training in infection prevention and control. The DON said when the full-time IP was on leave, she was assigned to work as the interim IP. The DON had completed some classes on infection prevention but had not met requirements to obtain an IP certificate.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/18/2023 and 09/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.