Greenfield Care Center of Fairfield

Based on interview, and record review the facility failed to ensure safe and effective pharmaceutical services for a census of 55 residents when Resident 41 and Resident 47's controlled drug (drug with potential for abuse) uses and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) were not documented in their Medication Administration Record (MAR-a legal document that list administered drugs).This failed practice may contribute to unsafe controlled medication handling and/or risk of controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace).Findings:1a. A review of Resident 41's clinical record indicated Resident 41 was admitted May of 2020 and had diagnoses that included gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), neuralgia (pain caused by irritation or damage to a nerve), and neuritis (inflammation of a nerve causing pain).A review of Resident 41's active physician's order, dated 4/25/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices were followed when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 55. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 36 opportunities which resulted in a facility wide medication error rate of 8.33% in one out of 9 residents (Resident 32) observed for medication administration.These failures had the potential for unsafe and ineffective medication use for Resident 32 and had the potential to negatively affect the residents' medical conditions.Findings:During a medication administration observation which started on 9/8/25 at 10:54 a.m. with Licensed Nurse (LN) 1, LN 1 administered a total of six pills to Resident 32 which included 1 capsule of aspirin-dipyridamole (a medication used to prevent stroke) ER (extended release) 25-200 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure pharmaceutical products were properly handled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 55 when:1. Multiple expired wound dressings (a material applied to a wound to protect it, promote healing, and prevent infection) were stored in the treatment cart;2. An expired medicated shampoo prescribed for a resident was stored in the treatment cart; and,3. An out of the package syringe needle (injection needle) was found in the treatment cart.These failures had the potential for residents to receive pharmaceutical products that were expired or with unsafe or reduced potency, and risk for residents and/or staff injury and/or infection.Findings:1. During a concurrent observation and interview which started on [DATE] at 11:38 a.m. with Treatment Nurse (TN) 2, of the facility's treatment cart, five silicone wound dressing (a type of wound dressing used to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enrich the caloric content of meals for five of seven residents (Resident 3, Resident 4, Resident10, Resident 37 and Resident 42) with fortified (increased calorie and/or protein content) dietary orders when the cook omitted the scoop of melted butter intended for fortification. This failure had the potential to put these residents at risk for poor nutritional status. Findings:A review of Resident 3's admission record indicated Resident 3 was admitted on [DATE] with the diagnosis of Multiple Sclerosis ( MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). A review of Resident 3's physician (MD) orders indicated an order, dated 12/4/23, for a fortified diet. A review of Resident 4's admission record indicated Resident 4 was admitted on [DATE] with a diagnosis of a Stage 3 pressure injury (Full thickness loss of skin, dead and black tissue may be visible).A review of Resident 4's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety when:1. Four steamtable pans were found wet, stacked in the ready to use shelves. 2. One cook failed to follow food safety/sanitation procedures while preparing cooked ready to eat foods.3. One diet aide was observed putting a clean and sanitized dish rack on the kitchen floor.These failures had the potential to lead to food borne illness for the 51 residents eating facility prepared meals.Findings:1) During an observation of the initial kitchen tour on 9/8/25 at 8:57 a.m., four steamtable pans were observed to be stacked wet (wet nesting) on the bottom shelves in the food preparation area, which indicated they were ready to use. During an interview, on 9/8/25 at 9:22 a.m., with the Dietary Supervisor (DS), the DS stated that wet nesting is not desirable. The DS confirmed the observation of the wet trays and instructed the dishwasher to re-wash them. During a review of the facility's policy and procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 55 when:1. A shared manual blood pressure machine (a device which measures blood pressure), a shared stethoscope (a device used to listen to the body's internal sounds), and a shared pulse oximeter (a medical device that measures the pulse rate and oxygen level in the blood) was not sanitized properly in between use of residents.2. One facility staff did not remove or properly cover a bracelet under personal protective equipment (PPE) while performing wound care for Resident 25.3. Enhanced Barrier Precaution (EBP, an infection control intervention that utilizes the use of gowns and gloves during direct care activities to reduce transmission of multi-drug-resistant organisms) guidelines were not followed for Res 5 and Res 53.These failures had the potential to spread germs and cause infection for a census of 55. Findings: 1. During an observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility, and prevent decline in range of motion (ROM) for two out of 19 sampled residents (Resident 30 and Resident 23) when:1. Resident 30's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed; and,2. An RNA program referral from Physical Therapy (PT) was not implemented for Resident 23.This failure had the potential for Resident 30 and Resident 23 to experience a decline in range of motion and/or function and not achieve their highest practicable physical wellbeing.Findings: 1. A review of Resident 30's clinical record indicated Resident 30 was admitted June of 2023 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one out of 19 sampled residents (Resident 2) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 2's gastrostomy tube (G-tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was not flushed with water before medication administration and enteral feeding.This failure had the potential for Resident 2 to experience complications of the G-tube such as clogging and for the resident not to attain his highest practicable well-being.Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted November of 2023 and had diagnoses that included encounter of gastrostomy status, dysphagia (swallowing difficulties), and hemiplegia (complete loss of the ability to move one side of the body).A review of Resident 2's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one out of 19 sampled residents (Resident 8) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 8's pain medication order was not consistently followed.This failure had the potential for Resident 8 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), experience unrelieved pain, and not attain her highest practicable well-being.Findings:A review of Resident 8's clinical record indicated Resident 8 was admitted January of 2025 and had diagnoses that included arthritis (a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), muscle spasm, and need for assistance with personal care. A review of Resident 8's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/22/25, indicated Resident 8 had a Brief Interview for Mental Status (BIMS- a tool to assess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to adhere to resident's food preferences as listed on their meal ticket for three of 14 sampled residents, Resident 32, Resident 4, and Resident 42 when:1. Resident 32 was served pot roast, but her meal ticket indicated that she disliked meat; and 2. Resident 4 was served brussels sprouts that was on her list of food dislikes.3. Resident 42 was given polenta (side dish made from cornmeal) with a documented corn allergy.These deficient practices had the potential for Resident 32, Resident 4, and Resident 42 to refuse to eat, potentially leading to weight loss, worsened medical conditions like slow wound healing, and a weakened immune system and for Resident 42 to have an allergic reaction.Findings: 1. Resident 32 was admitted in the facility on 6/10/25 with diagnosis that included Hypertension (high blood pressure) and Hyperlipidemia (high levels of fats in the blood). A review of Resident 32's Minimum Date Set (MDS, an assessment tool used…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to facility after the facility sent the resident to emergency room (ER). This failure resulted in denial of Resident 1's rights to return to the facility, which resulted in the resident's continuation of unnecessary hospital stay while waiting for placement. Findings: A review of the facility's ' Policy and Procedure on admission Screening,' dated 7/2012, stipulated, The main criteria for admission are the facility is equipped and be able to provide the needed care and services of the resident. The policy indicated further, The Director of Nursing .will assess the resident's concerns based on the information provided .for resident admission .If the assessment result revealed that the facility has the capacity to provide the needed care and services .based on medical background, other concerns such as physical and psychosocial needs .administrator or designee will give the Go signal for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide adequate supervision, accurate assessment, and interventions for one of 3 sampled residents (Resident 1) to prevent the resident leaving the facility, when Resident 1 left the facility without staff's knowledge (eloped), crossed a busy street, and was found wandering on the parking lot of another facility. This failure resulted in exposing Resident 1 to health hazards and fatal accidents. Findings: A review of the admission Record indicated the facility admitted Resident 1 on 4/3/25 after a brief hospitalization. Resident 1's multiple diagnoses included depression, muscle weakness and difficulty in walking. A review of Resident 1's hospital records dated 3/24/25 indicated the resident was brought to the hospital with confusion, weakness, and frequent falls at home. A review of the hospital document titled, Inter-Facility Transfer Report dated 4/3/25 indicated that Resident 1 was diagnosed with acute encephalopathy (impaired/altered mental status) caused by stroke (brain injury). The document indicated the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for two of 31 sampled residents (Resident 16 and Resident 266) when: 1. Resident 16's call light system was not appropriate; and, 2. Resident 266's call light system was broken, and she was provided with a nonfunctional alternative. This failure placed Resident 16 and Resident 266's safety at risk and had the potential for the residents' needs to be not met. Findings: 1.A review of Resident 16's clinical record indicated Resident 16 was admitted January of 2025 and had diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), need for assistance with personal care, muscle weakness, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures, and lack of expected normal physiological [functioning] development in childhood). A review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool) Cognitive Patterns, dated 2/5/25, indicated Resident 16 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure garbage was in a closed dumpster for a census of 60 residents when a dumpster was observed overflowing, and the lid was unable to be closed. This failure had the potential to attract insects and pests that could affect the health and safety of a highly vulnerable population of 60 residents, and could lead to the spread of infection among staff, and visitors. Findings: During an observation and concurrent interview, on 3/11/25, at 10:09 a.m. with [NAME] 1 (CK 1), the facility's kitchen and garbage dumpster area was inspected. CK 1 acknowledged the dumpster was overflowing and the lid could not close. CK 1 added, to fix this issue the facility could schedule an extra dumpster pick up. During an interview on 3/11/25 at 2:29 p.m. with the facility's Registered Dietitian (RD), the RD stated dumpster lids should be closed to prevent attracting pests. A review of facility policy and procedure titled, Food Related Garbage and Rubbish Disposal, revised 01/25, indicated It is the policy of this facility that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect resident privacy and confidentiality when meal tray tickets were thrown into the trash for a census of 54 out of 60 residents who ate facility prepared meals. This failure had the potential for 54 residents' personal and protected health information to be exposed and unprotected from unintended access. Findings: During an observation and concurrent interview in the kitchen on 3/11/25 at 10 a.m., with Dietary Aide 2 (DA 2), DA 2 was observed washing the breakfast dishes. DA 2 removed the food trays from the cart, dumped leftover food, dropped a used resident meal tray ticket on the floor, then picked it up and discarded it into the regular kitchen trash garbage can. When questioned, DA 2 stated this was her usual process. During an interview in the kitchen on 3/11/25 at 10:05 a.m., with [NAME] 2 (CK 2), CK 2 confirmed after resident meals are served and consumed, meal trays are then returned back to the kitchen for washing, and when there are trays containing used resident meal tickets on them, his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure two out of 31 sampled residents (Resident 264 and Resident 265) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 264 and Resident 265's pain medication order was not followed. These deficient practices negatively affected the residents' physical comfort and psychosocial well-being as evidenced by unnecessary pain and emotional distress which caused sleeplessness and resulted in unmanageable pain levels. Findings: 1a. A review of Resident 264's clinical record indicated Resident 264 was admitted February of 2025 and had diagnoses that included osteoarthritis (OA- a deteriorating disease that causes pain, stiffness, and swelling where two or more bones meet), pain in right hip, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body), chronic pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1h. During a review of Resident 28's Progress Note dated 1/31/25 at 3:35 p.m. indicated she was admitted to the facility on [DATE] around 12:30 p.m. During a review of Resident 28's Order Summary Report for January 2025 contained a physician's order dated 1/31/25 for Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated (to treat difficulty breathing and reduce swelling in the airways) one puff inhale two times a day. Review of Resident 28's January 2025 MAR indicated the Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated was to be given twice a day at 9 a.m. and 5 p.m. The MAR indicated on 1/31/25 at 5 p.m. the Licensed Nurse (LN) documented 5 in the initial box. Under the section Chart Codes on the MAR indicated 5=Hold/See Nurse Notes. Review of a Progress Note (Type: eMAR Medication Administration Note) dated 1/31/25 at 6:26 p.m. indicated Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 500-50 mcg (micrograms)/act (actuation) 1 puff inhale orally two times a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe medication administration practices when the facility's medication error rate was less than 5% for a facility census of 60. The facility had a total of 3 errors out of 30 opportunities, which resulted in a facility wide medication error rate of 10%. These failures had the potential to negatively affect the health of Resident 48 and Resident 16. Findings: During a medication administration observation on 3/10/25, that started at 12:14 p.m., Licensed Nurse 2 (LN 2) added less than half of a 5 -ounce cup of water to 17 grams (unit of measure) of Polyethylene Glycol powder (medication used for bowel regularity) for Resident 48. During a medication administration observation on 3/11/25, that started at 8:10 a.m., LN 3 added less than half of a 5-ounce cup of water to 17 grams of Polyethylene Glycol powder for Resident 16. A review of the manufacturer's Directions for Polyethylene Glycol powder indicated the powder is to be dissolved in any 4 to 8 ounces of beverage. During an interview on 3/12/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to safely store medications when, unused medications from a discharged resident (Resident 41) were stored in the bottom drawer of the Medication Cart C (Med Cart C) and an expired narcotic for Resident 15 found in the bottom drawer of Med Cart C. These failures had the potential to contribute to unsafe medication use and storage, and potential for diversion. Findings: During a concurrent observation and interview on [DATE] at 3:24 p.m., Licensed Nurse 4 (LN 4) opened Med Cart C for inspection. The following medications were observed stored in the bottom drawer: Pantoprazole (used to treat acid reflux and heartburn) 40 mg (milligrams, a unit of measure) tablets. Nifedipine (used to treat high blood pressure and chest pain) 30 mg tablets. Morphine Sulfate Oral Solution (used to treat moderate to severe pain) - Solution expired [DATE]. The LN 4 stated These [medications] should not be in here. I will remove them right now. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a full-time Dietary Manager / Supervisor position was filled, when a kitchen staff member, lacking the training and qualifications for the Dietary Manager / Supervisor role, was placed in the position to cover for the Dietary Manager during a leave over the past 4 months. This failure had the potential for providing inadequate nutritional needs for a census of 60 residents. Findings: During an interview on 3/10/25, at 8:51 a.m., with facility full-time [NAME] 1 (CK 1), CK 1 stated that the full-time Dietary Manager went out on a medical leave approximately mid-November in 2024. CK 1 stated she and the facility staff do not know when or if the Dietary Manager will be returning. CK 1 stated she is covering for the Dietary Manager, and reports to the facility Administrator, (ADM). CK 1 acknowledged she does not have the regulatory training and certification required for the Dietary Manager / Supervisor position. CK 1 stated the facility does have a part-time Registered Dietician (RD) with whom she communicates with on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prepare and store food in a sanitary manner for 54 residents who received food from the kitchen out of a census of 60 residents when: 1. Sanitizing solution was found to be under the minimum effective concentration, 2. Dietary Aide 1 (DA 1) did not cover his facial hair/beard while working in the kitchen, 3. Foods found in containers that were not sealed or closed tightly, 4. Foods found without labels indicating their use by date (expiration date), 5. Expired food found in food storage area, 6. Dishware found in ready to use areas in unsanitary condition. These failures had the potential to result in foodborne illness for all facility residents receiving food from the kitchen. Findings: 1. During a concurrent observation and interview, on 3/10/25 beginning at 8:53 a.m., [NAME] 1 (CK 1, who is the acting Dietary Manger), confirmed the presence of a red plastic bucket, stored on the counter of the dishwashing sink, which contained Quaternary Ammonia sanitizing solution (Quat, a disinfectant solution containing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 60 when: 1. Facility staff did not wear required personal protection equipment (PPE) while providing wound care to Resident 13 who was on enhanced barrier precautions (EBP-also known as enhanced standard precautions, infection control intervention designed to reduce transmission of multidrug-resistant organisms that employes targeted gown and glove use); 2. A caregiver did not wear required PPE while providing care for Resident 17, who was on EBP; 3. Facility staff did not wear required PPE while providing direct care for Resident 53, who was on EBP; 4. Facility staff did not perform hand hygiene prior to and after medication administration; and, 5. Licensed nurse did not properly disinfect the glucometer (device for measuring the concentration of glucose [main type of sugar in the blood and is the major source of energy for the body's cells] in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Effective Communications in-services were done as a mandatory training for direct care staff for a census of 60. This failure had the potential to result in staff with poor communication skills and may negatively affect the residents' quality of care. Findings: During a concurrent interview and record review on 03/12/25 10:41 a.m. with the Director of Staff Development (DSD), the DSD's 2024/2025 In Service Calendar [NAME] Care Center of Fairfield was reviewed. The DSD confirmed there was no communication in-service listed on the in-service calendar and confirmed he had not conducted any communication training in 2024 or 2025. During a review of the facility's policy and procedure titled, In-Service Training Program, revised 01/25 indicated, It is the policy of this facility to develop an effective in-service training program . Our in-service training program (staff development) is planned and conducted for the development and improvement of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that in-direct staff members (staff that do not provide direct resident care) were educated on the rights of the residents and the responsibilities of a facility to properly care for its residents, for a census of 60. This had the potential for residents to not recieve care according to their rights. Findings: During a concurrent interview and record review on 03/12/25 10:41 a.m. with the Director of Staff Development (DSD), the DSD's 2024/2025 In Service Calendar [NAME] Care Center of Fairfield was reviewed. The DSD confirmed training on the rights of the resident and the responsibilities of a facility to properly care for its residents was not conducted for indirect staff members. During a review of the facility's policy and procedure titled, In-Service Training Program, revised 01/25 indicated, It is the policy of this facility to develop an effective in-service training program . Our in-service training program (staff development) is planned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement a systematic and interdisciplinary approach to maintaining and improving safety and quality in nursing homes while involving residents and families in practical problem solving) ) for a census of 60. This deficient practice had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care. Findings: During a concurrent interview and record review on 03/12/25 10:41 a.m. with the Director of Staff Development (DSD), the DSD's 2024/2025 In Service Calendar [NAME] Care Center of Fairfield was reviewed. The DSD confirmed there was no QAPI listed on the in-service calendar and confirmed he had not conducted any training that outlines and informs staff of the elements and goals of the facility's QAPI program in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct staff training on behavioral health for a census of 60. This had the potential for staff to not have the knowledge to care for residents with behavioral health issues and needs. Findings: During a concurrent interview and record review on 03/12/25 10:41 a.m. with the Director of Staff Development (DSD), the DSD's 2024/2025 In Service Calendar [NAME] Care Center of Fairfield was reviewed. The DSD confirmed there was supposed to in-service conducted on Problems and needs of the aged, chronically ill acutely ill and disabled patients in April. The DSD confirmed he had not conducted this in-service in 2024. During a review of the facility's policy and procedure titled, In-Service Training Program, revised 01/25 indicated, It is the policy of this facility to develop an effective in-service training program . Our in-service training program (staff development) is planned and conducted for the development and improvement of skills of all our…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain dignity and respect for three out of 60 sampled residents (Resident 160, Resident 45, Resident 6) when: 1.Certified Nurse's Assistant 2 (CNA 2) made demeaning and rude comments to Resident 160 for using the commode rather than the restroom. This resulted in Resident 160 to feel humiliated and embarrassed. 2a. Certified Nurse 6 (CNA 6) was standing over Resident 45 while assisting him with his meal; and 2b. CNA 3 was standing over Resident 6 while assisting him with his meal. These failures caused embarrassment and had the potential to minimized the residents' feelings of self-worth. Findings: 1. A review of Resident 160's admission record indicated she was admitted to the facility on [DATE] with a diagnosis of Surgical Aftercare following surgery on the sense organs (surgery performed on organs related to the senses such as eyes or ears.) A review of Resident 160's Minimum Data Set (MDS- a federally mandated assessment tool), dated 3/10/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident 48's admission Record, indicated, Resident 48 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia (paralysis on one side of the body), Epilepsy (brain disorder characterized by recurring seizures) and Dysphagia (difficulty swallowing). During an interview with a family member (FM) of Resident 48 on 3/10/25 at 12:30 p.m., the FM stated, Resident 48's right upper arm and right lower leg are contracted and he's unable to move them. The FM was frustrated with the staff when she visited Resident 48 and found his call light on his right side of the bed. The FM further stated, Resident 48 should always have the call light within his reach, on his left side, so he can call for help anytime. During a concurrent observation and interview inside Resident 48's room with LN 2 on 3/10/25 at 2:50 p.m., Resident 48 was lying down on a Geri chair (reclining chair), away from his bed, and no call light was seen within his reach. LN 2 confirmed that Resident 48 had been laying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record reviews, the facility failed to practice appropriate infection prevention and control measures for one out of six sampled residents (Resident 1), when his Foley catheter (FC- a hollow tube inserted into the bladder to drain or collect urine) drainage bag was left on the floor. This failure had the potential to cause Resident 1 to experience a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: A review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in August of 2024 with diagnoses of muscle weakness, essential hypertension (HTN- high blood pressure) and neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged leading to impaired bladder control). A review of Resident 1 ' s Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/9/24, indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record reviews, the facility failed to ensure two out of six sampled residents (Resident 1 and Resident 2) had their call light (a device used to communicate with staff when assistance is needed) within reach. This failure could impair the residents ' ability to call for assistance when needed, potentially leading to safety concerns and delays in getting necessary care. Findings: A review of Resident 1 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in August of 2024 with diagnoses of muscle weakness and neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged leading to impaired bladder control). A review of Resident 2 ' s Face Sheet indicated Resident 2 was admitted to the facility in October of 2022 with diagnoses of hyperlipidemia (HLP- high cholesterol) and anemia (a condition where the body does not have enough healthy red blood cells). During a concurrent observation and interview on 2/5/25 at 12:05…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four out of four sampled residents received care which met professional standards when: 1. One Resident (Resident 1) suffered a 22 day delay in treatment of urinary tract infection and 2. three residents (Residents 3, 5 and 7) did not receive medications per order which had the potential to result in a stroke, high blood pressure, and for one resident (Resident 7) who suffered breathing problems and requested to be transferred to a facility for a higher level of care through emergency transport. Findings: 1. During a review of Resident 1's, admission Record , indicated Resident 1 was admitted to the facility on [DATE] with a history of urinary tract infection, diabetes (a chronic disease which occurs when your sugar levels are too high), acute kidney failure (sudden decline in kidney function which could be caused by infection or condition which reduce blood flow to the kidneys) and high blood pressure. During a review of Resident 1's Orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents and or their Responsible Parties (RP, an individual who is designated by the resident to help with placement or take on some responsibility for the resident's well-being) were aware of any Change of Condition (COC, significant alteration in a person's health or functional status that will not usually resolve itself without further intervention) or medication order changes, for two out of two sampled residents (Residents 2 and 3), when: 1. Resident 2 ' s RP was not notified of the change of his skin status. 2. Resident 3 was not aware he would need to continue his intravenous (IV, administered into a vein) antibiotic (ABX, drug used to treat infections-growth of germs in the body) therapy. This failure could potentially lead to delayed interventions, missed opportunities for quality care, for Resident 2 and for Resident 3 feeling anxious, angry and frustrated for not knowing the treatment plan. Findings: A review of Resident 2 ' s…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to: 1. Ensure Licensed Nurse (LN A) was following the Physician ' s Order for one out of two sampled residents (Resident 1), when LN A injected the long-acting insulin (injectable medication used to control blood sugar for people with Diabetes Mellitus -- DM,high blood glucose group of diseases that result in too much sugar in the blood) on Resident 1 ' s right lower abdomen at 11:18 a.m. instead of 9 a.m., per physician ' s order. 2. Ensure the nurse practitioner ' s (NP) treatment plan and recommendations on 10/31/24, were followed for one out of two sampled residents (Resident 2), when Resident 2 ' s current Electronic Treatment Administration Record (ETAR, digital systems used in healthcare settings to document the administration of treatments to patients) for 11/2024, did not reflect the NP ' s treatment plan, and Resident 2 was not on alternating pressure pad (APP, an air-flow mattress, a device that redistributes pressure to relieve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure proper infection protocol was provided for one out of two sampled residents (Resident 1), when licensed nurse (LN) A reused an alcohol wipe (a sterile wipe saturated with a high concentration of alcohol used to clean the skin and prevent infection) to wipe Resident 1 ' s abdomen after insulin (injectable medication used to control blood sugar for people with Diabetes Mellitus -- DM, high blood glucose group of diseases that result in too much sugar in the blood) administration. This failure put Resident 1 at risk for risk for infection by introducing germs and bacteria into broken skin. Findings: A review of Resident 1 ' s face sheet (demographics) indicated Resident 1 was admitted on [DATE], with diagnoses of DM, Chronic Pain (pain that lasts over three months) and Hyperlipidemia (HLP, a condition in which there are high levels of fat particles (lipids) in the blood). Resident 1 ' s Brief Interview for Mental Status (BIMS,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all facility staff received training in CPR (Cardiopulmonary Resuscitation, an emergency life-saving procedure performed when the heart stops beating) for healthcare providers, when four Certified Nursing Assistants (CNAs) did not have CPR certifications and did not know the facility's policy and procedure (P&P) for CPR. This failure reduced the facility's potential to provide life-saving procedures to residents during a medical emergency such as a resident having a heart attack or breathing failure. Findings: During an interview on [DATE] at 1:18 p.m. with the Director of Staff Development (DSD), the DSD stated some CNAs in the facility were not CPR certified. The DSD further stated CNAs were not able to perform CPR but instead would look for a licensed nurse if a resident was having a heart attack or failing to breathe. During an interview on [DATE] at 10:10 a.m. with the Director of Nursing (DON), the DON stated CNA's that were not CPR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure services met professional standards for one resident (Resident 10) of eight sampled residents when: 1. Licensed Staff B (LS B) administered Tacrolimus (a medication used in the prevention and treatment of organ transplant rejection) 0.5 milligram (mg) (medication to prevent the activity of the immune system) without a prescriber's order. 2. Tacrolimus 4.5 mg dose was changed by LS B without discussion with transplant coordinator (health professional who manages the organ transplant care); and, 3. Resident 10's weekly Tacrolimus lab was not done and carried out per prescriber's order. This failure decreased the facility's potential to administer medications safely to residents. Findings: A review of an admission Record indicated Resident 10 was admitted to the facility in early 2024 with multiple diagnoses which included dementia (loss of cognitive functioning - thinking, remembering, and reasoning) and history of heart transplant. Resident 10's Minimum Data Set (MDS, an assessment tool), dated 5/28/24 indicated, mild…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent accidents for one of 4 sampled residents (Resident 1) when a non-skid mesh, an intervention used to minimize risks of sliding from the wheelchair cushion and falling was not consistently implemented. This failure had the risk potential to increase falls and injuries for Resident 1. Findings: According to the 'admission Record', Resident 1 was admitted to the facility in the summer of 2018 with diagnoses of epilepsy (a brain condition causing recurrent seizures) and muscle weakness. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/12/24 was reviewed and indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. A fall risk assessment, dated 4/15/24, indicated a fall risk score of 19. According to the Fall Risk Assessment, a score of 10 and greater was considered as High Risk for falls. The Fall Risk Assessment also indicated Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of four residents (Resident 2) was free from abuse when facility staff witnessed Resident 1 punch Resident 2 in the face, resulting in Resident 2 sustaining a swollen upper lip, scratches on his right forearm and scratches on his left-hand middle finger. This failure resulted in Resident 2 not being free from abuse. Findings: Resident 1 was admitted to the facility early 2024 with multiple diagnoses which included thrombosis (blood clot), emphysema (lung disease that causes shortness of breath), and hypertension (high blood pressure). A review of Minimum Data Set (MDS, an assessment tool), dated 6/17/24, indicated Resident 1 was cognitively intact. Resident 2 was admitted to the facility middle 2018 with multiple diagnoses which included epilepsy (a brain disease that causes seizures), dementia (a loss of cognitive function), and depression. Review of MDS, dated [DATE], indicated Resident 2 had severely impaired cognition.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a care plan with interventions to support one of three residents (Resident 1) with pneumonia (an infection of the lungs that causes shortness of breath and respiratory distress) after Resident 1 had a change in condition indicating the onset of pneumonia. This failure placed Resident 1 at risk of respiratory discomfort and exacerbation of pneumonia. Findings: A review of Resident 1 ' s admission Record indicated he was admitted to the facility on [DATE] with diagnoses of heart failure (inability of the heart to pump enough blood through the body) and pressure ulcers (injuries to the skin and tissue below the skin due to prolonged pressure on the skin). A review of Resident 1 ' s clinical record indicated he had a change in condition on 6/1/24 when he experienced respiratory distress. A review of document titled SBAR Communication Form dated 6/1/24, at 9:34 p.m., indicated the following: SITUATION .The change in condition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to: 1) employ staff who treat the residents (Resident 12, 31 and 18) with respect and dignity; and, 2) the facility did not follow its policy with regards to the laundry services, resulting in one of one sampled Residents (Resident 7) refusing to wear anything other than a patient gown (a type of gown usually worn in hospitals which does not close in the back, it only has ties to attempt to close the back part). This left Resident 7 not trusting the laundry services to return her personal clothes and left her not feeling like an individual. Findings: 1. During an interview on 3/18/24 at 11:12 a.m., with Resident 18's Family Member (FM), the FM indicated there was an unlicensed staff member who was informed that Resident 18 needed to be changed and left the room. The unlicensed staff member did not return until the call light was turned on, the same unlicensed staff member returned and did not change Resident 18. The call light was pressed again and for a third time the same unlicensed staff member came to the room and did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to meet professional nursing standards for 5 of 23 sampled residents (Resident 35, 33, 21, 12 and Resident 47), when: 1. Resident 35 and Resident 33, who had pressure ulcers (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time) were provided with Low Air Low (LAL) Mattress (mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown); however, the air mattress was not inflated according to the resident's weight, and the facility staff did not follow its policy and procedure for, Pressure-Reducing Mattresses, Pressure Relieving Mattresses and Support Surfaces. This failure had the potential for Resident 35 and Resident 33 to develop new pressure ulcers and a potential worsening of an existing pressure ulcer; 2. Licensed Nurses did not administer pain medication for Resident 35 according to the doctor's order. This failure had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and records review, the facility failed to ensure showers for one of 23 sampled residents (Resident 21) were given during his scheduled shower days. This failure to maintain Resident 21's personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial and fungal infections. Findings: During a review of the Face Sheet (A one-page summary of important information about a resident) indicated Resident 21 was admitted on [DATE], with diagnoses including but not limited to: Diabetes Mellitus (disease that result in too much sugar in the blood); Morbid obesity (resident weighs 100 pounds over his recommended weight); and Hemiplegia and Hemiparesis (paralysis of one side of the body). During a review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 3/10/24, indicated Resident 21 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive ([relating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to provide activities to meet the needs and preferences for four of 23 sampled residents (Residents 12, 21, 33, and 40). This failure resulted in Resident 12 feeling lonely, isolated, and depressed. Residents not receiving activities, according to their preference and needs, could potentially impact their physical, mental, and psychosocial well-being. Findings: Resident 12 During a review of Resident 12's, admission Record, dated 7/25/22, indicated Resident 12 was admitted to the facility on [DATE], with a history of surgical amputation of left foot, major depression and heart disease. During a review of Resident 12's, quarterly MDS (Minimum Data Set, a clinical assessment process provides comprehensive assessment of the resident's functional capabilities and helps staff identify problems), dated 2/14/24, indicated: Resident 12 had a BIMS (Brief Interview of Mental Status) score of 13, which showed mild cognitive impairment. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to ensure it was adequately staffed for Certified Nursing Assistants (CNAs), for 20 out of 30 days, and two out of 21 days for Licensed Nurses, for the month of 1/2024, which resulted in complaints of the facility being inadequately staffed. This could put residents' safety at risk, falls, accidents, late provision of care or care not being rendered at all. During an interview on 1/30/24 at 10:42 a.m., Resident 2 stated staff did not pay attention to residents and that was why, people here fall all the time. He stated, Do you see anyone supervising me or other patients? Resident 2 stated he felt the facility was inadequately staffed, the staff were lazy and did not want to do the work. During an interview on 2/23/24 at 1:31 p.m., Licensed Staff F stated the facility was short staffed but was better compared to before. Licensed Staff F stated the facility did not really like to give overtime and it was hard, but she tried to finish her tasks on time. Licensed Staff F stated short staffing was not good for the residents, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide one sampled lunch test tray which had the appropriate temperature for the vegetables and meat, and the vegetables were not palatable. These failures had the potential to increase weight loss and one out of two sampled residents (Resident 7) frustrated that the hot food was served cold. Findings: During an interview on 3/18/24 at 12:08 p.m., Resident 7 indicated the food was not palatable nor was the hot food served hot. Resident 7 indicated the mayonnaise, served to the residents, did not taste like mayonnaise and could not identify what it tasted like. During a concurrent observation and interview on 3/20/24 at 1:03 p.m., with the Surveyor, the Dietary Supervisor (DS) and Registered Dietician (RD), a test tray was sampled regarding the meat and vegetable for temperatures and palatability. The spinach was tested in the conference room and indicated to be 101 degrees. The RD indicated this was not an acceptable range per regulatory guidelines. During a review of the facility's, Food Temperatures, dated 1/2024,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to label items in the freezer with their contents or delivery date and failed to discard expired fresh fruit. These failures had the potential of serving residents food not fit for consumption and enabling residents to become sick by ingesting expired food. The Dietary Supervisor indicated the cause of the colder temperature might be due to the plate being cold and not having resided in a hot plate warmer prior to being served. The meat (meatloaf) entrée was tested in the whole form and in the pureed form and both were found to be bland and not palatable. The spinach was watery in texture and not having any taste, also considered not palatable. Findings: During a concurrent observation and record review on 3/18/24 at 9:58 a.m., with the Dietary Supervisor (DS), the DS indicated the package in the freezer, without a label to identify the contents or the date regarding the receipt of contents, was a package of diced turkey. The DS produced a plastic bag in the freezer with the similar looking contents which had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement Committee (QAPI, a data driven and proactive approach to quality improvement; process used to ensure services are meeting quality standards and assuring care reaches a certain level) failed to identify quality deficiencies and subsequently investigate and act upon the deficiencies, once identified, as evidenced by: 1. Facility leadership failed to identify nursing staff were not providing services, per facility policy and professional standards, regarding bowel care management and RNA (Restorative Nurse Assistants; staff with special knowledge, skills, and techniques in therapeutic rehabilitation; work alongside rehabilitation staff caring for patients with limited mobility and capacity for self care) services (Cross reference F658); 2. Nursing staff repeatedly failed to identify and address pain, and subsequently contact the provider (Physician, Nurse Practitioner, or Physician Assistant) for strategies to improve pain management (Cross reference F697); and, 3. Nursing staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation, interview and record review, the facility failed to have a plate warmer in the kitchen in fully operational condition. Failure to have a functional plate warmer resulted in residents not having hot food for their meals, potentially causing weight loss due to lack of palatability. Findings: During a concurrent observation and interview on 3/20/24 at 12:30 p.m., with Dietary Manager (DM) and Registered Dietician (RD), during the lunch tray line, the plate warmer on one side was empty, and the cook was taking plates from one side of the warmer and placing them on the other side. The DM was standing next to the Surveyor, and a red button on the side the of the plate warmer was off, and the DM was asked if that was why the plates were being loaded to the other side. The DM was attempting to press the button in order for the red light to go on but after multiple attempts, it did not. Surveyor place her hand over the side of the plate warmer which was not lit and no warmth was felt. The DM was asked if one side of the plate warmer was broken. The DM kept pressing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to: 1. Report the verbal altercation between Residents 30 and 49 to the California Department of Health (CDPH, the State department responsible for public health in California) timely. 2. Ensure staff were aware of the correct reporting time fame for reporting abuse allegations to the CDPH, the Ombudsman (an official who investigates complaints, usually lodged by private citizens against businesses, public entities, or officials) and the local Police Department (PD). 3. Include in the Abuse Prohibition policy the correct time frame on when to report abuse allegations to the CDPH, the Ombudsman, and the local (PD). These failures led to the late reporting of abuse allegations to the CDPH, the Ombudsman and the local PD. These failures could also lead to ongoing abuse and residents feeling anxious and depressed. Findings: A review of Resident 49's face sheet (demographics) indicated he was initially admitted to the facility on [DATE], with diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure injuries of unknown source (the source of injury was not observed by any person or the source of injury could not be explained by the resident and the injury is suspicious because the extent of the injury or the location of the injury is located in an area not generally vulnerable to trauma) was thoroughly investigated and reported to the appropriate agency, for one out of one resident (Resident 38). This failure could lead to not knowing the extent of injury, worsening of an injury or the incident to recur. Findings: A review of Resident 38's face sheet (demographics) indicated she was 71 years-old, initially admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (AD, a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record, the facility failed to provide one of one sampled resident (Resident 12) follow-up psychiatric services to correspond with anti-depression medications. This failure resulted in Resident 12's depression to increase and failure to participate in therapy services, which now had encouraged Resident 12 to remain bed-bound and subjecting Resident to 12 to contractures and pressure sore development. Findings: During a review of Resident 12's, admission Record, dated 7/25/22, indicated Resident 12 was admitted to the facility on [DATE], with a history of surgical amputation of left foot, major depression and heart disease. During a concurrent interview on 3/18/24 at 3:43 p.m., with Resident 12 and her Care Giver, the Care Giver indicated Resident 12's depression had gotten worse, and she would not get up out of bed and participate with therapy. The Care Giver indicated Resident 12 would get up out of bed and participate in therapy if the Care Giver was present to encourage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the baseboards in residents' rooms were well maintained, were properly sealed and attached firmly to the wall. This failure could result in safety issues, cross-contamination, and pest infestation. Findings: During an environmental round (assessment of residents' environment to ensure the safety and well-being of residents, staff, and visitors) with the Infection Preventionist (IP) on 2/21/24 at 10:39 a.m., a part of the baseboard in the bathroom leading to room [ROOM NUMBER] was broken. During an interview on 2/21/24 at 10:45 a.m., the IP stated base boards should always be firmly attached to the wall. The IP stated, if baseboards were broken, undone and not fully attached to the wall, it could lead to vermin and pests getting inside the facility. The IP stated vermin and pests could bring disease inside the facility and could result in residents getting sick. During an environmental round with the IP on 2/21/24 at 10:49 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a safe environment for residents who frequently used the Activity Room, Dining Room, Lobby, Hallway, and a resident ' s room, when: 1) Residents 1 & 2 had a verbal altercation in the hallway. 2) Residents 3 & 4 had a physical altercation in the Dining/Activity Room on 11/18/22. 3) Residents 5 & 6 had verbal altercation while in the bathroom. 4) Residents 7 & 1 had a loud verbal altercation in front of other residents during an activity in progress in the Activity Room on 8/1/23. Resident 7 had multiple verbal altercations while raising his arms and was very angry at the staff while in his room & hallways on 8/10/22. These failures had the potential to result in fear of getting physically hurt, feeling anxious and frequent exposures to a noisy and hostile environment by residents, staff, and visitors. Findings: A record review titled, admission records, of Resident 7 indicated Resident 7 was admitted on [DATE], with a diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement its Policy & Procedures titled, Unusual occurrences, when it did not report multiple altercations for 5 out of 5 sampled residents (Residents 1, 2, 5, 6 & 7) to the State Agency (SA), to the Local Police Department (LPD) and to the State Ombudsman. These failures had the potential to results in physical harm due to frequent and multiple altercations, that may possibly lead to more serious physical injury and possible death. Findings: A record review of Resident 1 ' s admission Record indicated Resident 1 was admitted on [DATE]. Resident 1 had a BIMS score of Zero (0), dated 4/10/23, indicating severe impaired cognition, with diagnoses of Diabetes & Dementia (Diabetes is a disease that occurs when your blood glucose, also called blood sugar, is too high. Glucose is your body's main source of energy. Dementia is a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to inform the Responsible Party (RP=Responsible Party is the person who has a level of control over, or entitlement to, the funds or assets in the entity that, as a practical matter, enables the individual, directly or indirectly, to control, manage or direct the entity and the disposition of its funds and assets) of one of three sampled residents, Resident 7, before sending Resident 7 for a procedure (CT scan of the neck -- A computerized tomography (CT) scan combines a series of X-ray images). This failure had the potential to result in a feeling of uncertainty and unawareness by the Responsible Party when Resident 7 had a change of condition requiring a CT scan, leading to dissatisfaction of services provided. Findings: During an interview on 9/28/23 at 11 a.m., the Director of Nursing (DON) stated Resident 7 was sent for a CT scan of the neck on 9/15/23. The DON stated the result of the CT scan was sent to the Medical Doctor (MD) on a compact disc (CD).The DON stated Licensed nurses were to notify the Responsible Party…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that three (3) out of five (5) Licensed Nurses (LN), LN I, LN N, LN T (Charge nurses) implemented the Competency training (Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) to keep residents safe when: 1) There was no Staff Supervision while Residents 3 & 4 were alone in the dining/activity room. Residents 3 & 4 had a physical altercation in 11/18/22. There were no witnesses to confirm the event. 2) There were no documentation's by Licensed Nurses (LN) and IDT (Intradepartmental Team) in Resident 7 ' s medical records when Resident 7 had verbal altercation; and Resident 7 ' s changes of behavior such as very angry, irate, and frequently screaming at staff and other residents. Licensed nurse staff did not document, monitor, and record the frequency of occurrences when any new onset and unusual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure transfer notice was provided for one of two sampled residents (Resident 1), when Resident 1 was transferred to the hospital without notifying the Long-term Care Ombudsman Program. This failure did not ensure the Ombudsman was duly notified, to advocate for Resident 1's best interest during transfer from the facility. Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE]. During a record review for Resident 1, the Progress Note titled, Nurses Notes, dated 11/05/22 at 5:16 p.m., indicated, [Family Member A] called 911 (fire service personnel provide initial response to 911 calls in fire trucks) without telling the staff anything. He claimed [Resident 1] was having trouble breathing, but never once made any of the staff aware. Paramedic (a healthcare professional who responds to emergency calls for medical help outside of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure notice of the bed hold policy was provided to one of two hospitalized residents (Resident 1). This failure could have resulted in Resident 1 ' s being unaware she could return to the facility after hospitalization, and whether she needed to submit payment to reserve a bed. Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE]. During a record review for Resident 1, the Progress Note titled, Nurses Notes dated 11/05/22 at 5:16 p.m., indicated, [Family Member A] called 911 (fire service personnel provide initial response to 911 calls in fire trucks) without telling the staff anything. He claimed [Resident 1] was having trouble breathing, but never once made any of the staff aware. Paramedic (a healthcare professional who responds to emergency calls for medical help outside of a hospital) arrived and took [Resident 1] to the ER…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record reviews, the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public, when there were holes noted in the building roof, causing water leaks when it was raining. This failure had the potential to cause accidents, falls and injuries. Findings: During an interview on 3/28/23 at 10:58 a.m., Unlicensed Staff A verified Hallway A had a leaky roof, and staff would always use garbage cans to prevent the water from spilling on the floor. Unlicensed Staff A stated the leaky roof was noted about three weeks ago. Unlicensed Staff A stated the water leaks usually happened when it was raining hard. Unlicensed Staff A stated, It takes a while for the water to leak but tonight or tomorrow it ' s going to start leaking again due to heavy rain. Unlicensed Staff A stated the leaky roof was patched by maintenance but was ineffective. Unlicensed Staff A stated, if the leaky roof was not fixed immediately, it could result in residents,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.