Columbine Manor Care Center

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper storage of liquid oxygen.

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 .. 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 con.. 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 a.. 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 .. 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.. 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.. 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 surve.. 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 w.. 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.Ga.. 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... 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 closingNF.. 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... 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 s..

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 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 fa.. 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 physicia.. 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 poli.. 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 tempera.. 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 .. 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..