Fairpark Health And Rehabilitation

Based on facility policy review, observations, and interview, the facility failed to ensure an employee's personal food items were not stored in the kitchen reach-in cooler and failed to ensure frozen food items were stored properly, which had the potential to affect 70 of 71 residents residing in the facility. The findings include: Review of the facility's policy titled, Food Storage: Cold, dated 10/2019, revealed .frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .all food items are to be stored properly in covered containers . During an observation and interview with the Dietary Manager (DM), on 6/29/2025 at 10:18 AM, of the back reach-in cooler, revealed one purple lunch box and (one) 20-ounce carbonated beverage stored beside the residents' food items for meal service. The DM confirmed the purple lunch box and the carbonated beverage belonged to a dietary employee and should not be stored with the residents' food items. During an observation of the reach-in freezer on 6/29/2025 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, observations, and interviews, the facility failed to ensure the residents' health information remained private and confidential on 1 medication cart (Back 100 cart) of 4 medication carts observed, which had the potential to allow unauthorized individuals access to the residents' private health information. The findings include: Review of the facility's policy titled, Confidentiality of Personal and Medical Records, dated 1/2/2020, revealed .facility honor the resident's right to secure and confidential personal and medical records .safeguarding the content of information including written documentation .computer information from unauthorized disclosure without the consent of the individual .resident's personal or medical information shall not be left unattended or viewable by unauthorized persons . During an observation on 7/1/2025 at 9:33 AM, on the 100 hall, revealed the residents' sensitive health information was present on the computer screen on the medication cart (back-100 hall). Further observation revealed there was a written shift-to-shift…

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 Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, facility policy review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #68) of 20 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the facility's policy titled, RAI Assessment- MDS 3.0 Completion, revised 6/1/2025, revealed .Residents are assessed .using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .According to federal regulations, the facility conducts .accurate .assessment of each…

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, observations, and interviews, the facility failed to perform appropriate hand hygiene when serving residents' meal trays for 3 residents (Resident #55, #11, and #38), the facility failed to wear appropriate Personal Protective Equipment (PPE) when delivering the meal tray for 1 resident (Resident #69), and the facility failed to offer hand hygiene assistance prior to meals for 1 resident (Resident #50) of 18 residents observed for meal tray distribution. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 6/9/2025, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .Hand hygiene is a general term for cleaning your hands by handwashing .or antiseptic hand rub .hand hygiene is indicated and will be performed .Between resident contacts . Review of the facility's policy titled, Transmission-Based Precautions, dated 5/21/2025, revealed .take appropriate precautions to prevent…

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 prevent a medication error for 1 resident (Resident #40) of 6 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Medication Administration, revised 6/1/2025, revealed .Medications are administered .as ordered by the physician and in accordance with professional standards of practice .Identify resident by photo in the MAR [Medication Administration Record] .Review MAR to identify medications to be administered .verify resident name, medication name, form, dose, route, and time . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Morbid (Severe) Obesity, and Chronic Pain Syndrome. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident 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 facility policy review, medical record review, observations, and interviews the facility failed to maintain a safe, clean, homelike environment on 1 of 2 hallways, and 5 resident's (Resident #37, #418, #1, #39, and #15) rooms of 15 rooms observed. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, revised 2/20/2024, showed .It is the policy of this facility to ensure the provision of routine cleaning .to provide a safe, sanitary environment .Cleaning refers to the removal of visible soil from objects and surfaces . During an observation on 3/18/2024 at 10:28 AM, in Resident #37's bathroom showed a black mat under the sink visibly dirty with dust and debris. A black fan in the room on a base, the base was dusty and dirty. Further observation showed the 2 doors at the sink had chipped missing paint and the baseboard had visible dirt, dust, and dark colored debris in the creases. During an observation on 3/18/2024 at 10:35 AM, in Resident #418's room showed the floor had dark scuff marks, the area under the sink had broken pieces…

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 review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a significant change assessment for 1 resident (Resident #36) of 20 residents reviewed. The findings include, Review of CMS's RAI Version 3.0 Manual Chapter 2 dated 10/2023 revealed .Guidelines to Assist in Deciding If a Change Is Significant or Not .When a .Resident enrolls in a hospice program .must be within 14 days from the effective date of the hospice election . Resident #36 was admitted to the facility on [DATE] with diagnosis including Diabetes, End Stage Renal Disease, Hypertension, and Anemia. Review of Resident #36's current physician orders showed hospice care was ordered on 8/21/2023. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Further…

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 review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 residents (Resident #39, #36 and #33) related to the use of anticoagulants, hospice, and restraints of 20 residents reviewed. The findings include: Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2023 showed .Anticoagulant [medication used to prevent blood clotting] .Do not code antiplatelet medications such as .clopidogrel [also called Plavix is an antiplatelet medication used to prevent blood clotting] .Code residents identified .in a hospice program .Identify all physical restraints that were used at any time .during the 7-day look-back period .code 0, not used .if the item was not used . Resident #39 was admitted to the facility on [DATE] with diagnoses including Diabetes, End Stage Renal Disease with Dialysis, Peripheral Vascular Disease, Amputation…

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 interview the facility failed to develop a baseline care plan for 1 resident (Resident #3) of 20 residents reviewed. The findings include: Review of the facility policy titled, Baseline Care Plan, dated 3/22/2022, showed .The facility will develop .a baseline care plan for each resident that includes the instructions needed to provide effective .person-centered care of the resident .The baseline care plan will .Be developed within 48 hours of a resident's admission . Review of the facility policy titled, admission of a Resident, dated 3/22/2022, showed .initial/baseline plan of care will be developed during admission process . Resident #3 was admitted to the facility on [DATE] with diagnoses including Right Hip Fracture, Dementia, Dislocation of Right Hip, Depression, and Adult Failure to Thrive. Review of the medical record showed a baseline care plan had not been developed within 48 hours of admission. The initial care plan was developed on 1/2/2023…

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 follow a physician's order for 2 residents (Residents #61 and #418) of 3 residents reviewed for wounds. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Pressure Ulcer to Buttocks. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #61 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment, and had a Stage 1 and Stage 2 pressure ulcer upon admission. Review of a Diet Order & Communication document dated 1/25/2024, showed Resident #61 .Diet Order .Double protein portions at all meals . The document was signed by the Registered Dietician (RD). Review of a dietary Progress Note dated 1/25/2024, showed .Will add double protein portions at meals as resident had good appetite to promote wound healing . Further review showed the document 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, safety data sheet review, medical record review, observations, and interviews the facility failed to ensure chemicals were secured in resident (Resident #37, #8, and #41's) bathroom. The findings include: Review of the facility's undated policy titled, Handwashing, Chemical Use, and PPE [Personal Protective Equipment], showed .Chemical Use .chemicals should be locked at all times . Review of a Safety Data Sheet, revised 6/12/2015, showed .Product Name Clorox .Regular-Bleach .Information on toxicological effects .May cause redness and tearing of eyes .May cause redness or burns to skin .Inhalation may cause coughing . Review of a Safety Data Sheet, revised 1/18/2019, showed .Ingredient Name .Benzisothiazolin-3-0ne [antimicrobial agent and preservative in products like multi-purpose cleaning agents, stain removers, and is used in water- based solutions] .Toxicological Information .Expected to be a low ingestion hazard . Resident #37 was admitted to the facility on [DATE] 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, facility policy review, and interview, the facility failed to ensure 1 resident (Resident # 54) of 20 sampled residents received trauma-informed care in accordance with professional standards of practice and accounting for a resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The findings include: Resident #54 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, fracture of Right Femur, Muscle Weakness, and Post Traumatic Stress Disorder. Review of the facility policy titled, Trauma Informed Care, revised 3/15/2023, showed .Trauma is defined as an event, a series of events, or set of circumstances experienced by an individual as physically or emotional .common sources of trauma may include .physical emotional .abuse at any age .each resident will be screened for a history of trauma upon admission .the facility will account for residents' experiences,…

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 maintain mechanical equipment in a safe operating condition in 2 of 2 dryers observed in the laundry room. The findings include: Review of the facility's undated policy titled, Next Level Hospitality Services Chapter 2 Linen Operations and Management, showed .All lint screens must be cleaned and brushed every hour and after every single load . During an observation of the laundry room on 3/20/2024 at 3:20 PM, showed the dryer lint screens of both dryers with thick layer of lint build up on the screens and lint accumulation lying on the floor under the dryers. Further observation showed the Lint Trap Clean Out Log had not been completed for 3/20/2024. During an interview on 3/20/2024 at 3:20 PM, the Environmental Services Manager (ESM) confirmed the 2 dryers had a thick layer of lint build up on the screens and lint accumulation lying on the floor under the dryers. She confirmed the cleaning of the dryer screens had not been documented for 3/20/2024. The ESM stated the person responsible 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.