Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with nutritional and food safety standards, including adherence to menus, proper preparation and serving of therapeutic and mechanically altered diets, and sanitary food handling practices in the kitchen.
Findings
The facility failed to follow the weekly menu to meet residents' nutritional needs, including not offering milk as specified and serving incorrect mechanically altered diets to residents #38 and #10. Additionally, food safety violations were observed, including unsafe food holding temperatures, kitchen staff not wearing appropriate hair restraints, and improper handling of ready-to-eat foods.
Deficiencies (5)
Failure to follow the weekly menu to ensure adequate nutrition was provided to residents, including not offering milk and incorrect side items.
Failure to ensure residents were served the correct mechanically altered diets, resulting in residents #38 and #10 receiving regular texture meals without prompting.
Failure to maintain safe holding temperatures for food items, including hot foods below required temperature and nutritional supplements above safe cold holding temperatures.
Failure to ensure kitchen staff wore appropriate hair restraints, specifically a cook with facial hair not wearing a beard net.
Failure to handle ready-to-eat foods in a sanitary manner, including kitchen staff touching bread and other ready-to-eat foods with bare hands after handling non-food items.
Report Facts
Temperature of hot food: 133.1
Temperature of cold food: 45.5
Temperature of cold food: 48.9
Temperature of cold food: 44.7
Temperature of nutritional supplement: 59
Temperature of nutritional supplement: 68
Temperature of nutritional supplement: 62
Performance improvement plan start date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Cook | Prepared incorrect diet textures and was observed not wearing beard net |
| Dietary Aide #1 | Dietary Aide | Handled ready-to-eat foods with bare hands during dinner service |
| Dietary Aide #2 | Dietary Aide | Interviewed about beverage offerings and menu adherence |
| Registered Dietitian | Registered Dietitian | Interviewed multiple times regarding menu adherence, diet textures, and food handling |
| Regional Dietary Consultant | Regional Dietary Consultant | Interviewed regarding menu items and diet texture standards |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about education on altered diet textures |
| Speech Language Pathologist | Speech Language Pathologist | Interviewed about residents' diet texture orders and swallowing issues |
| Nutrition Services Director | Nutrition Services Director | Interviewed about food temperature standards and kitchen staff roles |
| Registered Nurse #1 | Registered Nurse | Interviewed about preparation and maintenance of medication cart coolers |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with nutritional, food safety, infection control, and dietary service regulations at Fairacres Manor, Inc.
Findings
The facility failed to follow menus to meet residents' nutritional needs, did not serve correct mechanically altered diets to specific residents, failed to maintain safe food holding temperatures, did not ensure kitchen staff wore appropriate hair restraints or handled ready-to-eat foods properly, and failed to maintain proper infection prevention and control practices including cleaning and disinfecting resident rooms and high-touch surfaces.
Deficiencies (3)
Failure to follow the weekly menu to ensure adequate nutrition was provided to residents, including not offering milk as a beverage and not serving correct altered texture diets to Residents #38 and #10.
Failure to ensure food was prepared, distributed, and served under sanitary conditions, including unsafe food holding temperatures, lack of appropriate hair restraints, and improper handling of ready-to-eat foods.
Failure to maintain an infection prevention and control program, including improper cleaning techniques, inadequate training of housekeeping staff, and failure to adhere to disinfectant dwell times.
Report Facts
Temperature of tuna melt sandwich: 133.1
Temperature of garden salad tray 1: 45.5
Temperature of garden salad tray 2: 48.9
Temperature of cheesecake slice: 44.7
Temperature of MedPass nutritional supplement on Sagewood wing cart: 59
Temperature of ReadyCare nutritional supplement on Sagewood wing cart: 68
Temperature of ReadyCare nutritional supplement on Pinebrook wing cart: 62
Dwell time for Bay TableTop Sanitizer: 3
Dwell time for Bay Acid Free Disinfectant Restroom Cleaner: 10
Performance improvement plan start date: Mar 15, 2024
Performance improvement plan estimated completion date: Mar 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook #1 | Cook | Named in findings related to incorrect preparation of mechanically altered diets and food handling |
| Dietary Aide #1 | Dietary Aide | Named in findings related to failure to offer milk and improper handling of ready-to-eat foods |
| Dietary Aide #2 | Dietary Aide | Interviewed regarding beverage offerings during meals |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed multiple times regarding menu adherence, diet texture compliance, and food handling |
| Regional Dietary Consultant | Regional Dietary Consultant (RDC) | Interviewed regarding menu and diet texture compliance |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed regarding education on altered diet textures |
| Speech Language Pathologist | Speech Language Pathologist (SLP) | Interviewed regarding diet texture orders and resident swallowing safety |
| Nutrition Services Director | Nutrition Services Director (NSD) | Interviewed regarding food temperature standards and kitchen staff responsibilities |
| Registered Nurse #1 | Registered Nurse (RN) | Interviewed regarding medication cart cooler preparation and temperature monitoring |
| Housekeeper #1 | Housekeeper | Observed and interviewed regarding cleaning practices and disinfectant use |
| Housekeeping Laundry Manager | Housekeeping Laundry Manager (HLM) | Interviewed regarding cleaning policies, disinfectant dwell times, and housekeeping audits |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and cleaning protocols |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 13, 2020
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, medication management, infection control, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), improper use of physical restraints, inadequate pressure ulcer prevention and care, environmental safety hazards causing resident injuries, medication administration errors, improper medication storage and labeling, food safety violations, and ineffective infection prevention and control practices.
Deficiencies (8)
Failure to provide a reasonable accommodation of needs for Resident #9 by not ensuring a touch pad call light system was available and within reach.
Failure to ensure residents were free from physical restraints imposed for staff convenience, including lack of assessments, physician orders, consents, monitoring, and care planning for lap belt use for Resident #13.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents #63 and #85, including delayed interventions, inadequate monitoring, and ineffective pressure relief measures.
Failure to ensure the environment remained free from accident hazards, resulting in Resident #99 sustaining multiple abrasions from the metal bar on the Hoyer lift during transfers.
Medication administration errors observed for Residents #105, #12, and #38, including incorrect dosing, improper medication form given, failure to ensure medication ingestion, and failure to rinse mouth after inhaler use.
Failure to ensure drugs and biologicals were labeled and stored properly, including expired medications in medication rooms and carts, undated opened insulin vials, unlabeled medication cups, and expired test kits.
Failure to maintain food safety standards including improper cold food holding temperatures, disinfecting chemicals not maintained at proper PPM, dented canned food items stored for use, improper storage of sugar, flour and utensils, and inadequate surface cleaning in the bistro area.
Failure to effectively implement an infection prevention and control program, including improper hand hygiene and PPE use by staff, inadequate cleaning practices leading to cross-contamination, contamination of resident food, and inadequate infection surveillance and investigation of transmission events.
Report Facts
Medication error rate: 16.67
Opened insulin vial age: 87
Opened insulin vial age: 56
Opened Tuberculin vial age: 74
Opened Tuberculin vial age: 70
Expired medication: 3
Calf measurements: 26
Calf measurements: 24
Egg salad temperature: 44
Egg salad temperature: 46
Disinfectant PPM: 0
Dented canned food items: 3
RSV outbreak duration: 29
RSV cases: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Replaced call light system for Resident #9 and provided interview about call light use |
| RN #5 | House Supervisor | Observed and corrected call light placement for Resident #9 |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors and medication room observations |
| LPN #3 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors |
| CNA #2 | Certified Nurse Aide | Observed and interviewed regarding infection control practices and resident care |
| AA #2 | Activity Assistant | Observed and interviewed regarding improper PPE use and infection control breaches |
| HSK #1 | Housekeeper | Observed and interviewed regarding improper PPE use and cleaning practices |
| HSK #4 | Housekeeper | Interviewed regarding cleaning responsibilities and infection control training |
| HLS | Housekeeping and Laundry Supervisor | Interviewed regarding staff training and cleaning protocols |
| SDC | Staff Development Coordinator | Interviewed regarding infection control surveillance and staff training |
| DD | Dietary Director | Interviewed regarding food safety and sanitation practices |
| DC | Dietary Consultant | Interviewed regarding food safety and sanitation practices |
| ANHA | Assistant Nursing Home Administrator | Interviewed regarding infection control breaches and staff reeducation |
| DCO | Director of Clinical Operations | Interviewed regarding infection control surveillance and improvement plans |
| DON | Director of Nursing | Interviewed regarding multiple findings including infection control, medication storage, and resident safety |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 21, 2019
Visit Reason
The inspection was conducted due to complaints and allegations regarding the use of physical restraints, failure to report and investigate injuries of unknown origin, failure to complete timely comprehensive assessments, failure to revise care plans after significant changes, and failure to provide appropriate respiratory care.
Complaint Details
The complaint investigation focused on allegations of improper use of physical restraints, failure to report and investigate injuries of unknown origin, failure to complete timely assessments and care plan revisions, and failure to provide appropriate respiratory care.
Findings
The facility failed to ensure residents were free from unnecessary physical restraints, failed to timely report and investigate injuries of unknown origin, failed to complete timely comprehensive assessments and care plan revisions after significant changes, and failed to provide appropriate respiratory care including proper physician orders and care plans for oxygen therapy.
Deficiencies (5)
Failed to ensure two residents were free from physical restraints without proper assessments and physician orders.
Failed to timely report and investigate an injury of unknown origin for one resident.
Failed to complete a timely comprehensive and accurate assessment after a resident returned from hospital with significant change in condition.
Failed to revise the comprehensive care plan timely after a significant change of condition for one resident.
Failed to provide respiratory care in accordance with professional standards, including lack of physician order and care plan for oxygen therapy for one resident.
Report Facts
Residents reviewed for restraints: 7
Sample residents: 39
Days delay in reporting injury: 56
Oxygen flow rate: 3
Oxygen saturation: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding restraint use, injury reporting, care plan revisions, and oxygen therapy. |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding Resident #60 and oxygen therapy for Resident #32. |
| Medical Director | Medical Director (MD) | Interviewed regarding use of watchmates and restraint necessity. |
| Clinical Quality Consultant | Clinical Quality Consultant (CQC) | Provided incident report and participated in interviews. |
| Occupational Therapist | Occupational Therapist (OT) | Interviewed regarding transfer methods and hematoma for Resident #29. |
| Physical Therapist | Physical Therapist (PT) | Interviewed regarding transfer methods and hematoma for Resident #29. |
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