VI AT HIGHLANDS RANCH SKILLED NURSING

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 11/5/24 for all previous deficiencies cited on 9/19/24. 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 facility is a three-story, Type II (222) structure. The structure is protected throughout by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The structure consists of an assisted living facility on the first (1st) and third (3rd) floors, with the long-term care facility located on the second (2nd) floor. All floors have direct egress to grade level (1st floor on the South and West sides, 2nd floor on the North and Southwest sides, and the 3rd floor on the East side with stair access on the West side). This survey, conducted on October 17, 2024, included a fire safety evaluation under Chapter 19 (Existing Health Care Occupancies) of the 2012 edition of NFPA-101, published by the National Fire Protection Association. The facility is required, for future inspections, to maintain and not diminish the facility features that meet the requirements for new construction at the time of licensure or certification. The survey result was discussed during the exit conference with the Administrator and the Maintenance Director.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101No Fire sprinkler semi-annual report at the time of inspection. NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Need fire smoke damper on oxygen room19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).(b)Not less than two separate smoke compartments shall be provided on each floor.(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The administrator discussed deficient items 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 an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey was conducted from 9/16/24 to 9/19/24. One deficiency was cited.

An Emergency Preparedness survey was conducted from 9/16/24 to 9/19/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure: -Foods were palatable in temperature; and,-Always available alternative menus were available for residents. Findings include:I. Facility policy and procedureThe Food and Beverage Operation Guide, dated 2024, was received from the nursing home administrator (NHA) on 9/19/24 at 8:00 a.m. It documented in pertinent part, "All food and display units maintain proper temperature to avoid contamination and deterioration. Appropriate times/temperature include: hot food display units must maintain food above 135 degrees Fahrenheit (F). Harmful microbes grow best in the temperature danger zone at 41 to 135 degrees Fahrenheit."II. Individual resident interviewsResident #16 was interviewed on 9/16/24 at 11:26 a.m. She said the food was always served cold when it was served to her in her room. She said she always ate toast for breakfast, and it was served cold and "rock hard." She said she did not enjoy the toast when it was served hard. She said she enjoyed chocolate ice cream with her meals and it often was served melted. She said it took a while to get her meals and they never came at the same time each day. Resident #17 was interviewed on 9/16/24 at 12:04 p.m. He said the food tasted terrible, there was no flavor in the food served and there was no variety. He said he was served chicken frequently and the facility did not mix it up. He said the food could be served hotter. He said he did not know how to get another option if he did not want what they were serving and there was no always available menu in his room. Resident #7 was interviewed on 9/16/24 at 2:43 p.m. He said he did not have access to the weekly menu. He said he did not have an always available menu. He said the food was served cold and did not taste right. He said the quality of food started changing when they changed to a new chef. Resident #13 was interviewed on 9/16/24 at 3:12 p.m. He said he generally did not eat lunch, however his main meals were breakfast and dinner. He said for the past several weeks the food was served cold. He said he complained to the staff about it but nothing so far had been done. He said he did not know there was an always available menu. He said when he did not like the food that was served, the staff told him to order a sandwich. Resident #13 was interviewed on 9/16/24 at 3:15 p.m. He said the food was served cold. Resident #4 was interviewed on 9/16/24 at 3:22 p.m. He said he usually would eat everything that was served. He said he ate his meals in his room and were sometimes served cold, but he did not ask the staff to heat it up. He said when the food was bad, it was bad at every meal that day. He said he was not aware he could order food from an always available menu because he did not know there was an always available menu. He said he was the resident council president and the residents had complained about the food quality and temperature during recent meetings. Resident #7 was interviewed again on 9/17/24 at 4:30 p.m. She said her lunch meal was served cold and did not taste right. She said she complained about the food at the resident council meeting a while back. She said the food quality changed when they hired a new chef. Resident #16 was interviewed again on 9/18/24 at 1:10 p.m. She said she had the chicken, eggplant parmesan, soup and chocolate ice cream for lunch on 9/18/24. She said the chicken, eggplant and soup were served cold. She said the ice cream was served melted. She said she did not enjoy the meal when it was served cold and the ice cream was melted. Resident #15 was interviewed on 9/18/24 a 1:15 p.m. She said the food was served cold and she could not eat it because it tasted so bad. She said she got the eggplant parmesan and chicken with mashed potatoes and gravy for lunch on 9/18/24. She also had soup that she said was served cold. She said the food sometimes was served warm but today it was served cold.. Resident #17 was interviewed again on 9/18/24 at 1:20 p.m. He said he had the chicken and eggplant parmesan for lunch on 9/18/24. He said it was served cold and he did not enjoy the chicken since he ate it almost daily. He said he was not aware there was an alternative menu or how to order something different. Resident #10 was interviewed on 9/18/24 at 4:17 p.m. He said he did not like chicken. He said he was told by a staff member to write a ham sandwich on the menu card if there was nothing else he would like from the daily menu options. He said there was not an always available menu on the menu card he was provided. III. Meal service and test tray observations Lunch meal service was observed on 9/17/24 beginning at 11:30 a.m. and ending at 1:05 p.m., the following was observed:Line cook (LC) #1 placed the pans that contained the food in the hot air wells table to maintain temperature through the end of the service to all residents. LC #1 took the temperatures of the food at 12:00 p.m. prior to leaving the main kitchen for meal service. LC #1 took the food cart to the memory care unit and served the residents. LC #1 then took the food cart to the assisted living unit and served the units. At 12:55 p.m. she started serving food to residents on the SNF unit. She did not recheck the food temperatures. A test tray for a regular diet was evaluated by two surveyors immediately after the last resident had been served their meal for lunch on 9/18/24 at 1:05 p.m. The test tray consisted of rosemary and garlic chicken, grilled flank steak with red wine sauce, roasted broccoli, sauteed shiitake mushrooms and mashed potatoes with gravy:-The chicken was 120 degrees F.-The beef was 115 degrees F. The beef tasted salty. -The broccoli was 105 degrees F. -The mushrooms were 105 degrees F.IV. Resident council meeting minutes The 6/4/24 resident council minutes revealed the residents reported if the temperature of the food they were served varied. They said the food served in the dining room was warm, but could be warmer. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 7/2/24 resident council minutes revealed the residents reported the food was often served cold. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 8/6/24 resident council minutes revealed the residents reported the food was not always hot, but they understood that the food had to be delivered from another building. The residents said the cold food was more of a problem for the residents who ate in their rooms. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. V. Culinary council meeting minutes The February 2024 culinary council meeting minutes documented the residents said the food was often served too cold and items were missing from the tickets, the food could be warmer, and they would like the food hotter when it was served. They said the food was cold when delivered as room trays and sometimes food was served cold in the dining room. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The April 2024 culinary council meeting minutes documented the residents said hot food should be served hot and cold food should be served cold.-There was no documentation indicating the steps the facility took to resolve the residents' concerns. The June 2024 meeting minutes documented the residents said sometimes there were long wait times between courses and the food gets cold in the dining room.-There was no documentation indicating the steps the facility took to resolve the residents' concerns. VI. Staff interviewsLine cook (LC) #2 was interviewed on 9/19/24 at 8:05 a.m. LC #2 said he was aware of the new convection ovens were installed in the kitchen about two months ago, however he did not know how to use it and was not trained on this appliance. Dietary aide (DA) #1 was interviewed on 9/19/24 at 8:25 a.m. DA #1 said the dietary staff took a weekly menu to the residents on Thursdays and asked the residents to choose food for next week. She said there was no always available menu the staff could use when residents did not like the food that was on the weekly menu. She said she usually suggested a variety of cold sandwiches to the residents if they did not like the menu options. The NHA was interviewed on 9/19/24 at 10:45 a.m. The NHAsaid he was not aware the residents did not have access to an always available menu. He said he was aware of the concerns regarding food being served cold to the residents and had been working on ways to improve the food temperature by making changes, renovations to the kitchen and working on a process improvement plan. He said there were residents that had grievances and concerns regarding the cold food that were discussed in the culinary council and resident council. The executive chef (EC) was interviewed on 9/16/24 at 10:15 a.m.. The EC said the food was stored, prepared and cooked in the main kitchen. He said the main kitchen was in the independent living facility. He said the food was then distributed by a vehicle to the skilled nursing facility (SNF). He said that one line cook was assigned to cook food for residents in the SNF in the main kitchen, then transported the ready to serve food to the care center, placed in the hot air wells table. The line cook served food to the residents in the kitchen in the SNF. He said the kitchen was remodeled approximately two months ago and the steam table was replaced with a new hot air table. He said two new convection ovens were installed so when the food got cold during the serving process the line cook could warm it up. The EC was interviewed again on 9/19/24 at 12:30 p.m. the EC said he was aware of residents being served cold meals. He said there were ovens in the kitchen that could be utilized to heat food and keep it hot until serving it. He said the expectation would be to serve foods at safe and palatable temperatures and if a food is lower, then before serving they should heat it up to the proper temperature.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This facility is a three-story, Type II (222) structure. The structure is protected throughout by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The structure consists of an Assisted Living on the first (1st) and third (3rd) floors with the Long-Term Care located on the second (2nd) floor. All floors have a direct egress to grade level (1st floor on the South and West sides, 2nd floor on the North and Southwest sides, and the 3rd floor on the East side with stair access on the West side). This survey conducted on March 202, 2023, included a fire safety evaluation under Chapter 19 (Existing Health Care Occupancies) of the 2012 edition of NFPA-101, published by the National Fire Protection Association. The facility is required, for future inspections, to maintain and not diminish the facility features that meet the requirements for new construction at the time of licensure or certification. The result of the survey conducted was discussed during the exit conference with the Administrator and the Maintenance Director.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101- Life Safety Code section 19.3.4 (2012) and NFPA 72-National Fire Alarm Code (2010). This was evidenced by the following:1. Missing semi-annual fire alarm inspection/testing/maintenance report. 2. 7/21/22 Two-year smoke detector sensitivity report does not include manufacturer device tolerance ranges. 3. Devices in Elevator Shafts 9 and 10 were not functionally tested during annual fire alarm inspection/testing/maintenance report from 7/5/2022.4. FACP breaker is not labeled in associated electrical panel. 5. FACP power supply batteries missing date labels. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. 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 jurisdiction14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. NFPA 72 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. Table 14.4.5 Testing Frequencies Component 15. Initiating Devices (e) Heat detectors (The requirements of 14.4.5.5 shall apply.)NFPA 72 10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit. 10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." 10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking. 10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel. NFPA 72 10.5.9.1.2 Where the battery is not marked with the month/year by the manufacturer, the installer shall obtain the date-code and mark the battery with the month/year of batterymanufacture. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the facility administrator and maintenance staff during the exit conference.

Through observation during documentation review and field inspection, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25 (2011). This was evidenced by:1. Missing annual fire suppression inspection/testing/maintenance report. NFPA 25 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. NFPA 25 Chapter 13: Valves, valve components, and trim. 13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the facility administrator and maintenance staff during the exit conference.

Based on observation during the survey, it was determined that the facility failed to meet the operational requirements in accordance with NFPA 101 (2012). This was evidenced by the following:1. Smoking area materials not disposed of properly in a non-combustible container. NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any otherhazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3) Smoking by patients classified as not responsible shall be prohibited.(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(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 affected smoke compartments. Deficient items were discussed with the facility administrator and maintenance staff during the exit conference.

Based on field observations, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Missing personal protective equipment for oxygen trans filling operations. NFPA 99 11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable. 11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic 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. 11.5.2.3.2 Transfilling to liquid oxygen portable containers at 344.74 kPa (50 psi) and under shall include the following:(1) The area is well ventilated and has noncombustible flooring.(2) The area is posted with signs indicating that smoking in the area is not permitted.(3) The individual transfilling the liquid oxygen portable container has been properly trained in the transfilling procedure.(4) The guidelines of CGA P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, are met. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the facility administrator and maintenance staff during the exit conference.

A recertification survey was conducted from 3/27/23 to 3/29/23. No deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/27/23 to 3/29/23. No deficiencies were cited.