Fairacres Manor, INC.

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Smoke Deficiencies

Construct fire resistant interior walls.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

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.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Provide properly protected cooking facilities.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

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

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. 1. The 2-year sensitivity report has most of the de.. Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.31. Fire doors near 301 need a sill.2. .. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19.South patio Gates missing exit signsNF.. Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" of the floor.. 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.. Based on observations and records review, it was determined that the facility did not have out-of-service guidance for the fire alarm in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not have proper verbiage NFP.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 25Out-of-service Sprinkler Guidance - Does not have .. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continui.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than hour apart not at varied timesNFPA 101, 19.7.1.6 Drills shall be c.. STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of th.. STANDARD is not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas in accordance with Life Safety Section 19.3.2.1. and 9.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on July 2. 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code .. Through observation and staff interviews of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes in accordance with NFPA101 Life Safety Code (2012 Edition), section 19.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. No 3-year dry valve inspection at the time of ins.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by: 1) Extension cord supplyin..

A recertification survey with complaint #CO35647 was completed on 6/3/24 to 6/6/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 6/3/24 to 6/6/24. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches);-Ensure housekeeping staff were trained appropriately on housekeeping procedures; and,-Ensure surface disinfectant dwell times (how long surfaces remained wet with disinfectant) were adhered to. Findings includeI. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleanin.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen.Specifically, the facility failed to:-Ensure safe holding temperatures for food items were maintained;-Ensure kitchen staff wore appropriate hair restraints when preparing and serving food to residents; and,-Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination.Findings include:I. Maintain safe holding temperatures for food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/10/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Time/temperature control.. Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to:-Follow the weekly menu to ensure adequate nutrition was provided to the residents; and, -Ensure Resident #38 and Resident #10 were provided with the correct mechanically altered diet. Findings include:I. Failure to follow the weekly menu to ensure adequate nutrition was provided to the residents A. Observations and record reviewReview of the menu and the menu extensions for the 6/3/24 lunch meal revealed that 2% (percent) milk was to be served.On 6/3/24 the lunch service was observed during a continuous observation in the main and rear dining rooms, beginning at 10:50 a.m. and ending at 11:58 p.m. -The d..