Fairview Haven

Based on observation, interview and record review the facility failed to monitor medication room freezer temperatures and failed to store medications separately from food. This failure affects all 47 residents residing in the facility. Findings include: The facility's Storage of Medications policy with a revised date of 9/10/24 documents, Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored in a separate compartment from food. On 9/10/24 at 10:15 AM, V3 Licensed Practical Nurse opened the medication storage room refrigerator and there was food and drink in the refrigerator. There was bisacodyl suppositories and acetaminophen suppositories in the bottom drawer of the refrigerator and there was a medication card of Florastor (probiotic) for R251 in the top shelf of the refrigerator door. V3 opened the freezer and there was no thermometer in the freezer. The freezer contained individual ice cream cups and popsicles. V3 confirmed there was no thermometer in the freezer…

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 implement fall prevention interventions for one of three residents (R27) reviewed for falls in the sample list of 34. Findings include: The facility's Falls-Clinical Protocol with a revised date of 5/3/13 documents, Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. R27's Order Summary Report dated 9/10/24 documents diagnoses including Unspecified Dementia, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety and Osteoarthritis. R27's Nurse's Notes dated 5/14/24 documents R27 was found on the floor in his room with an abrasion to the left elbow and to the forehead. R27's Care Plan dated 5/3/22 documents R27 is at risk for falls and documents an intervention dated 5/18/22 that non-skid footwear should be worn at all times. On 9/9/24 at 10:06 AM, 9/10/24 at 10:09 AM and on 9/10/24 at 2:18 PM, R27 was lying in bed sleeping 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.

Based on observation, interview, and record review the facility failed to initiate Enhanced Barrier Precautions for one (R14) of sixteen residents reviewed for infection control in a sample list of 34. Findings include: The facility's policy Enhanced Barrier Precautions dated 9/10/24 documents Enhanced Barrier Precautions expand the use of Personal Protective Equipment and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of Multidrug Resistant Organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization As well as for residents with MDRO infection…

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 dispose of unused medications from unknown residents. This failure has the potential to affect all 46 residents residing in the facility reviewed for medication disposal in the sample list of 18. Findings include: The facility's undated Discarding and Destroying Medications policy provided on 7/12/23 documents, Medications that cannot be returned to the dispensing pharmacy (e.g. {example} non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed. Non-controlled and Schedule V controlled drugs must be destroyed in the presence of two (2) licensed nurses. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. On 7/12/23 at 10:41 AM during the medication room tour, V15 Registered Nurse opened an unlocked drawer labeled CD (hall cart CD) and there were medication cards in the front of the drawer. V15 stated that V15 did not know where those medication cards came from or why they were 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 observation, interview and record review the facility failed to prevent injury during care transfers for a resident requiring total assist and protective sleeves to both arms. This failure affects one (R12) of three residents reviewed for transfers from a total sample list of 18. Findings include: R12's Minimum Data Set, dated [DATE] documents R12 as cognitively intact and requiring total assistance for transfers, including a mechanical lift. R12's skin care plan dated 6/19/23 documents R12 is to wear protective sleeves to both arms and may remove for hygiene. R12's progress notes document the following: 3/11/23 document a skin tear approximately one centimeter on the left leg 4/12/23 documents during a shower, R12 sustained a skin tear on the left elbow from the yellow (transfer) sling which had scraped R12's left elbow, approximately 1.5 cm .0.5cm. in size 5/9/23 document that R12' sustained a skin tear to R12's right forearm when transferring the resident. 5/25/23 documents, Bruising and skin tear…

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 complete a self administration of medication assessment for residents with medications at bedside for two of two residents (R4, R29) reviewed for self administration of medications on the sample list of 18. Findings Include: The facility's undated Self Administration of Medication Policy documents residents in our facility who wish to self administer their medications may do so if it is determined that they are capable of doing so. The staff and practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self administering medications and document their findings and the choices of the residents who are potentially capable of self administering medications. Self administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible, the medications will be kept in the medication cart and nursing will transfer 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 complete residents initial assessment for an antidepressant and failed to complete quarterly assessments for antidepressants and an antipsychotic medication. This failure affects one of five residents (R22) reviewed for unnecessary medications in the sample list of 18. Findings include: The facility's undated Psychotropic Medication Use policy provided on 7/12/23 documents, Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Discussion of non-medication behavior management strategies that could be implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment as well as on an ongoing basis. Primary care physician, PA (Physician's Assistant) or APN (Advanced Practice Nurse) Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month 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.

Based on observation, interview, and record review, the facility failed to maintain equipment and utensils in a safe, clean, sanitary condition to prevent the potential for cross-contamination of food from physical contaminants. These failures have the potential to affect all 47 residents in the facility. Findings include: 1.) On 6/21/2022 at 9:45 am on tour of the kitchen, accompanied by V8, Dietary Manager, there was a manual tabletop can opener. The tabletop can opener had thick, dark brown grease-like build-up on the blade and an accumulation of metal shavings in gears. V8, Dietary Manager stated I see the metal shavings. I will get that taken care of right away. That is bad and is a potential hazard that could affect all the residents in the facility. 2.) On 6/21/2022 at 9:50 am continuing on the tour of the kitchen accompanied by V8, there was one large 24 inch by 18 inch acrylic cutting board and two smaller 18 inch by 12 inch acrylic cutting boards. The three cutting boards each had deep slice-like divots over the majority of the boards The center sliced divot had imbedded…

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 PRN (as needed) medications were not ordered for more than 14 days maximum duration permitted for PRN medications without justification, failed to complete a psychotropic medication assessment prior to starting a psychotropic medication, and failed to care plan non-pharmacological interventions to assist with behavior management for three of five residents (R27, R30, and R36) reviewed for psychotropic medications on the sample list of 25. Findings include: 1.) R36's Physician Order Summary Report Sheet (POS) dated June 1-30, 2022, documents the following diagnosis: Unspecified Dementia Without Behavioral Disturbance, Anxiety Disorder Due to Known Physiological Condition, and Delusional Disorder. R36's Physician Order Summary Report Sheet (POS) dated February 1-28, 2022, documents the following psychotropic medication order: Lorazepam Tablet 0.5 MG( milligram) Give 1(one) tablet by mouth as needed (PRN) for Anxiety take every 12 hours. Active…

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 dignity was maintained by administering an injection in the dining room for one of six residents (R35) reviewed for medication administration on the sample list of 25. Findings Include: On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's ordered insulin injections and entered the dining room to administer it. R35 was sitting at the dining room table with R44 when V7 stated V7 needed to administer R35's insulin. R35 lifted R35's shirt to make R35's abdomen accessible to V7, and V7 administered the two insulin injections. On 6/22/22 at 8:44 am, R35 stated, staff normally don't give R35 insulin in the dining room but instead make R35 go to R35's room to get it. On 6/22/22 at 1:38 pm, V1 Administrator stated the facility does not have a policy for dignity. On 6/23/22 at 8:30 am, V10 RN (Registered Nurse)/Director of Senior Services stated we {facility} prefer staff not give injections in the dining room but there are some residents who request it though due to not wanting to go back to their…

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 a comprehensive care plan for anticoagulant therapy for one of 13 residents (R19) reviewed for care plans in the sample list of 25. Findings include: The facility's Care Plan - Comprehensive policy dated 3/28/19 documents, Policy Statement(:) An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem…

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 record review, observation, and interview, the facility failed to keep a resident's oxygen tubing off the floor and failed to label portable oxygen tubing according to facility policy. This failure affects two of three residents (R14 and R16) reviewed for respiratory care on the sample list of 25. Findings include: 1.) On 06/21/22 at 11:22 AM R14 was seated in a wheelchair at the side foot area of R14's bed. R14 had an oxygen bedside concentrator that was plugged into the wall outlet at the head of the bed. R14 had a portable oxygen tank on the back of R14's wheelchair. The bedside oxygen concentrator tubing was stretch out on the floor three feet from the concentrator to reach R14's wheelchair. The oxygen concentrator tubing had several feet of oxygen tubing coiled on the floor at the side of R14s wheelchair. R14 stated R14 just changed over to the portable oxygen in preparation to leave R14's room. R14 stated The oxygen tubing dangles from the concentrator and onto the floor sometimes. R14's portable…

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 administer medications according to Manufacturers Recommendations and facility policy for one (R35) of six residents reviewed for medication administration in the sample list of 25. The facility had 2 errors out of 33 opportunities for a medication error rate of 6.06%. Findings Include: R35's June 2022 POS (Physician Order Sheet) documents orders for Lantus {Long Acting Insulin} 10 units SQ (Subcutaneously) every morning and Novolog {Rapid Acting Insulin} 100 units /ml per sliding scale coverage SQ before meals and at bedtime{based on blood glucose level}: 151-175 = 1 unit, 176-200 = 2 units, 201-225 = 3 units, 226-250=5 units, 251-275=7 units, 276-300 = 9 units, 301-325 = 12 units, 326-350=15 units, and if greater than 351, call physician On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) stated V7 had already checked R35's blood glucose level, which was 162, therefore R35 would be receiving one unit of Novolog. V7 pulled an unlabeled Novolog Flexpen from the medication cart and prepared the ordered Novolog. 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.

Based on observation, interview and record review, the facility failed to ensure medications are labeled appropriately for one of six residents (R35) reviewed for medication labeling in the sample list of 25. Findings Include: The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date. On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's morning medications which included insulin's: Novolog {Rapid Acting Insulin} and Lantus {Fast Acting Insulin}. V7 pulled the unlabeled Novolog and Lantus from a bag in the medication cart that had a worn pharmacy label on it. The label had R35's name on it, which was barely legible due to being worn and no other information. V7 stated, V7 knew that the Novolog and Lantus belonged to R35 due to being in the bag that was labeled for R35.