The Preserve At Fairfield Glade

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration and physician's orders were followed for 1 resident (Resident #26) of 7 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Medication Administration Policy and Procedures, dated 6/2025, revealed Nurses prepare and administer medications, only with orders from a licensed prescriber and follow the community policies and procedures .Nurses follow the seven rights of medication administration including: Right resident, Right medication, Right dose, Right route, Right time, Right recording, and Right reason .All medication labels should be checked three (3) times with the eMAR [Electronic Medication Administration Record] prior to administration .Vital signs and blood sugar monitoring is done prior to giving medications as indicated per order .Check…

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 the Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #7) of 13 residents reviewed. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023, revealed .the assessment [MDS] accurately reflects the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and discharged on 7/27/2024 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Epilepsy, Diabetes Mellitus, Fracture of Lower End of Right Tibia, Fracture of Shaft of Right Tibia. Review of the Nurse's Notes for Resident #7 dated 6/18/2024 at 7:21 PM, revealed .Reason resident was hospitalized or received service at a hospital .CVA [Cardiovascular Accident] [Stroke], Right Hemiparesis, Seizure, Fall from standing .fall precautions .…

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 facility policy review, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan to address end of life care for 6 residents (Residents #20, #9, #13, #16, #27, and #34) and hearing loss for 1 resident (Resident #34) of 17 residents reviewed. The findings include: Review of the facility's policy titled, Care Plan-R/S, LTC, Therapy & Rehab, dated 9/22/2022, showed .Each resident will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care .will be modified to reflect the care currently required/provided for the resident .will emphasize the care .of the whole person . Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of a Physician Orders for Scope of Treatment…

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 facility policy review, medical record review, observation, and interview, the facility failed to ensure a privacy cover was maintained for a urinary catheter drainage bag for 1 resident (Resident #34) of 5 residents reviewed for urinary catheters, and failed to provide assistance to maintain desired physical appearance for 1 resident (Resident #34) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Grooming residents as they wish to be groomed .Refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered . Resident #34 admitted to the facility on [DATE], with diagnoses including Dementia, Heart Failure, Retention of Urine, Neuromuscular Dysfunction of Bladder, Urogenital Implants, and Atrial Fibrillation. Review of the annual…

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 facility policy review, medical record review, observation, and interview, the facility failed to ensure medical information was not visible for 1 resident (Resident #27) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Maintaining an environment in which there are no signs posted in residents' rooms .able to be seen by other residents and/or visitors that include confidential clinical or personal information . Resident #27 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia, Alzheimer's Disease, Delusional Disorders, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview of Mental Status (BIMS) assessment score of 12, which indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to ensure an allegation of employee to resident abuse was reported immediately to the facility administration and to the State Agency (SA) within two hours, in accordance with Federal Law, for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of facility policy titled, Abuse And Neglect-Rehab/Skilled, Therapy & Rehab, revised 12/23/2020 showed .Alleged or suspected violations involving .abuse .will be reported immediately to the administrator .other officials in accordance with state law .In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy review, medical record review, and interviews, the facility failed to investigate an allegation of abuse timely for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse And Neglect-Rehab/Skilled, therapy & Rehab, revised 12/23/2023, showed .If an employee received an allegation of abuse .the employee will then report the allegation to a supervisor .The .nurse will be notified immediately, assess the situation .complete an initial investigation . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #147 scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Review of a Care Plan note dated 4/18/2023, showed .up with extensive assist X 2 [times 2] with a stand aid .alert and oriented .Resident is…

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 implement a wound care intervention for 1 resident (Resident #7) of 3 residents reviewed for wounds. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia, Adult Failure to Thrive, Diabetes Mellitus, and Palliative Care. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severe cognitive impairment and was at risk for pressure ulcers. Further review showed the resident had 0 pressure ulcers on admission. Review of the comprehensive care plan initiated 11/1/2022 showed .potential for pressure ulcer development .nutritional problem r/t [related to] FTT [Failure to Thrive], T2DM [Type 2 Diabetes Mellitus] .hospice care . Intervention added on 11/14/2022 included .provide pillows to float heels while in bed .bilateral heel boots while in bed . Review of an order summary report for Resident #7 dated 11/14/2022, showed .Cleanse left inner foot wound 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 record review, observation, and interview, the facility failed to implement interventions to prevent accidents for 1 resident (Resident #20) of 3 residents reviewed for accidents. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #20 had moderate cognitive impairment and required extensive assistance of 2 staff with bed mobility, transfers, dressing, and toilet use. Resident #20 had a history of 1 fall since the last assessment. Review of Resident #20's care plan dated 2/17/2023 showed the resident was at risk for falls with interventions of a pad alarm to bed and tab alarm to chair to be used to alert staff and prevent accidents. During observation on 5/1/2023 at 12:16 PM, Resident #20 was observed in a common room for lunch, seated in a wheelchair with no alarms. During an observation and interview on 5/2/2023 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 facility policy review, observation, and interview, the facility failed to ensure medications were secured in 1 of 4 medication carts and in 1 of 4 treatment carts observed. The findings include: Review of the facility's policy titled, .Medications: Acquisition Receiving Dispensing and Storage, dated 3/2/2023, showed, .Medications will be stored in a locked medication cart, drawer, or cupboard . During an observation on 5/2/2023 at 7:48 AM, Registered Nurse (RN) #1 had left the medication cart unattended, with stock medications stored on top of the medication cart, while going to administer medications. During an observation and interview on 5/2/2023 at 8:10 AM, RN #1 had left the medication cart unattended, with medications stored on top of the medication cart, while going to administer medications. RN #1 stated she stored stock medications on top of the cart to prevent wear and tear on the medication cart drawers and to save time. RN #1 stated she felt like the stock medications on top of the cart was secure because she was at the medication cart most of the time. RN #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 medical record review, observation, and interview, the facility failed to adequately monitor and report an irregularity to the physician for 1 resident (#27) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia without Behavioral Disturbance, Restless Leg Syndrome, Type 2 Diabetes Mellitus, and Anxiety Disorder. Medical record review of the Order Summary Report, dated 11/13/19, revealed .mirtazapine [an antidepressant medication used to stimulate the appetite] tablet 7.5 mg [milligrams] .order date .4/24/19 . Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #27 was cognitively intact. Further review revealed the resident received an antidepressant daily. Medical record review of a Nutritional Status note, dated 8/30/19, revealed…

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.