Center at Centennial, the

Inspectors wroteBased on record review and interviews, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#25 and #31) of three residents reviewed for antibiotic use out of 33 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #25 and Resident #31.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 15 sample residents received adequate supervision and services to prevent an accident. Resident #1 was admitted to the facility on [DATE] with a traumatic subdural hemorrhage with loss of consciousness (intracranial bleeding between the brain and the skull), muscle weakness, aphasia (loss of the power of speech), hemiplegia (paralysis affecting one side of the body), Parkinson's disease (a condition that affects muscle control and movement), acute pain due to trauma and a history of falling. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for two (#2 and #3) of three residents reviewed for medication errors out of 15 sample residents. Specifically, the facility failed to ensure Residents #2 and #3 received medications as scheduled according to the physician's orders which resulted in significant medications errors.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled, dated, and monitored in refrigerators; -Ensure the kitchen equipment were clean and sanitary; -Ensure staff were utilizing proper personal hygiene practices; -Ensure holding temperatures of food were within the safe range; and, -Ensure systems were in place to prevent compromised food safety through proper staff training.

Inspectors wroteBased on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition and remove expired medical supplies from three of three emergency response crash carts. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart, to ensure the carts contained emergency equipment and expired items were removed and replaced.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hand held showers in 12 private shower rooms, increasing the risk of contamination to the facility's main water supply.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on four resident hallways.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 10 of 25 resident rooms in four hallways. Specifically, the facility failed to ensure walls, halls, ceilings, and floors were repaired, painted and properly maintained.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure the facility was free from accidents and hazards. Specifically, the facility failed to ensure the exit doors to the second and third floor balconies were locked from the outside without allowing building re-entry if locked outside.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the kitchen provided food that accommodated resident preferences for three (#27, #28 and #229) of six residents of 20 sample residents. Specifically, the facility failed to ensure Resident #27, #28 and #229 were receiving their menu choices.

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 in one of four halls including an isolation room. Specifically, the facility failed to ensure appropriate personal protective equipment (PPE) while providing care for Resident #136 who was positive for COVID.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and and does not develop pressure ulcers unless the individual's clinical condition demonstrates that the were unavoidable for one (#24) of four residents out of 40 sample residents reviewed for pressure ulcers. Resident #24 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke), abnormal posture and muscle weakness. Resident #24 skin was assessed at admission on [DATE] as not having any pressure areas identified. The facility identified the resident at low risk for developing pressure ulcers, however per the 12/17/21 minimum data assessment, he was identified at risk for developing pressure ulcers. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#221) of two residents out of 40 sample residents. Resident #221, who had diagnoses of low back pain, compression fractures in her lumbar and thoracic vertebrae, and left upper quadrant (abdominal) pain was admitted to the facility on [DATE]. The resident stated she had back pain and did not like to get out of bed much because she had more pain when she moved. The resident also stated that she ate most of her meals lying down in her bed because she had less pain when she was lying in bed. [...]

Inspectors wroteBased 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 disease and infection, including COVID-19. Specifically, the facility failed to: -Ensure staff and visitors wore the appropriate personal protective equipment (PPE) and performed appropriate hand hygiene when entering transmission-based precaution (TBP) rooms on one of four halls; -Ensure staff wore masks appropriately while in resident care areas on three of four halls; and, -Ensure residents were offered hand hygiene before meals on two of four halls.

Inspectors wroteBased on observation and interviews, the facility failed to follow infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, during testing procedures while the facility was in outbreak. Specifically, the facility failed to: -Disinfect surfaces within six feet of the collection/handling area thoroughly after each specimen test; and, -Disinfect the testing/specimen collecting area on an hourly basis.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for one (#24) of four residents out of 40 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to include Resident #24's wife in his care planning decisions.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#24, #49) of two residents reviewed for shower preferences out of 40 sample residents. Specifically, the facility failed to honor Resident #24's shower preference of twice weekly and the offer of a bath daily, and Resident #49's shower preference of every other day. Cross-reference F686, pressure ulcer for Resident #24.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (#131) of two residents reviewed for professional standards out of 40 sample residents. Specifically, the facility failed to have a physician's order in place for intravenous (IV) fluid that infused continuously for four days for Resident #131.

Inspectors wroteBased on resident interviews, staff interview, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure meals were served according to resident allergies and preferences for three of five residents out of 40 sample residents. Specifically the facility failed to: -Ensure Resident #275 was not served food that she was allergic to; and, -Ensure Resident #126 and #63 were served their preferred and recommended diet texture. I. Facility policy and procedure The Food Allergy policy, undated, was provided by the director of nursing (DON) on 1/25/22 at 11:33 a.m. It read, in pertinent part, No patient shall be served any food that they report as an allergy. All allergies should be strictly enforced. The Therapeutic Diets policy and procedure, reviewed February 2021, was provided by the DON on 1/25/22 at 11:38 a.m. [...]