Fair Park Health & Rehabilitation Center

Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 1 of 2 medication carts (Unit 2) reviewed for drug storage. On 05/13/2025, LVN D left the Unit 2 medication cart unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings included: An observation and interview on 5/13/25 at 7:46 AM revealed an unlocked medication cart was situated in a hallway across from the Unit 2 nurses' station. There was no nurse or medication aide seen in the vicinity of the cart. RN C approached from around a corner and stated she did not know why the medication cart had been left unlocked and believed that MA E had the keys. RN C was observed locking the cart. During an observation and interview on 5/13/25 at 7:50 AM, MA E was passing medications on the 100 Hall and stated she did not have the keys to the 200 Hall at that time and believed the nurse had them. During an interview on 5/13/25 at 8:47…

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 review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 05/12/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 05/12/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 05/12/25. 4. The facility failed to clean the 6 A/C vents in the kitchen on 05/12/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation of the facility's kitchen dry storage, refrigerator and freezer areas and the kitchen A/C vents on 05/12/25 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 interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one of (Resident #43) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary and a reconciliation of medications for Resident #43 when he planned discharge home on [DATE]. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home and/or discharged from the facility. Findings included: 1. Record Review of Resident #43's admission face sheet dated 03/08/2025 reflected that…

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 resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #22) reviewed for ADL care. CNA G failed to ensure Resident #22 was provided her shower as scheduled on the 2:00 PM to 10:00 PM shift on 5/12/25. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses included hypertension (high blood pressure); stroke; hemiparesis (muscle weakness or partial paralysis on one side of the body often caused by 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 interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of five (Resident #22) residents reviewed for pharmacy services. The Facility failed to ensure nursing staff ordered medications in a timely manner for Resident #22 resulting in her missing a scheduled morning dose of Robaxin used to control her muscle spasms on 5/13/25. This failure placed the residents at risk of not receiving medications as ordered by the physician and a delay in treatment and worsening of their condition. Findings included: Record review of Resident #22's admission Record dated 5/12/25 reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 9 indicating moderately impaired cognition. Her diagnoses…

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 review, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice for 2 (Resident #1 and #4) of 4 residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's nasal cannula, for the oxygen concentrator, was placed in a sanitary container when not in use. 2. The facility failed to ensure that Resident #4's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was changed. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #1's Face Sheet, dated 10/23/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included COPD, and history of pneumonia. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status…

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 that residents' environment remained free of accident hazards as was possible for 1 (Resident #2) of 3 residents reviewed for accident prevention. The facility failed to ensure Resident #2's bed was placed in the lowest position to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #2's Face Sheet, dated 10/23/2024, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included muscle spasms, lack of coordination, and muscle weakness. Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review 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 review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #3) of 6 residents were reviewed for pharmaceutical services. The facility failed to ensure that Resident #3 did not miss doses of medication that was to be administered at bedtime. This failure could place residents at risk of not receiving their medications as ordered by their physician. Findings included: Review of Resident #3's Face Sheet, dated 10/23/24, reflected that Resident #3 was a [AGE] year-old female admitted [DATE] with cerebral infarction (stroke: blood flow to the brain is blocked) affecting left non-dominant side, left elbow contracture (permanent tightening of the muscle), and unspecified pain. Review of Resident #3's Quarterly MDS (Minimum Data Set: screening tool to assess health status) Comprehensive Assessment, dated 10/02/24, reflected that Resident #3 had moderate cognitive impairment with a 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.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure refrigerator items were dated and labeled. 2. The facility failed to ensure ice scoop was left outside of ice bin. 3. The facility failed to ensure [NAME] A performed hand hygiene during lunch meal service on 4/4/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in the kitchen on 04/03/24 at 9:43 AM revealed a box of celery in the walk-in refrigerator that was not dated and labeled. Observation in the kitchen on 04/03/24 at 9:50 AM revealed a box of tomatoes in reach-in refrigerator that was not dated and labeled. Observation on 04/03/24 at 09:52 AM revealed that ice scoop was left inside the ice bin touching the ice cubes within the ice machine. Observation of lunch meal…

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 provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #19, Resident #22) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #19 had her fingernails cleaned and trimmed. 2- Resident #22 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Record review of Resident #19's Quarterly MDS assessment dated [DATE] reflected Resident #19 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis of one side of the body) affecting left side, lack of coordination, and contracture of the left elbow. Resident #19 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS…

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 provide treatment and services to prevent complications of enteral feeding for one (Residents #25) of one resident reviewed for feeding tubes in that: LVN B failed to check placement of Resident #25's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) by checking for gastric residual (quantity remaining) prior to administering the resident medications. This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort. Findings included: Record review of Resident #25's Quarterly MDS assessment, dated 04/03/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (swallowing difficulties), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and diabetes…

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 a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 (Resident #23) reviewed for respiratory care, in that: The facility failed to ensure Resident #23 Oxygen humidity bottle were labeled or dated. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met. The findings were: Review of Resident # 23s Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses include Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing- related problems), Congestive heart failure (compromised blood supply from heart to meet body's needs), Hyperlipidemia (high blood lipid level), Schizophrenia {severe mental disorder) and was on oxygen therapy in the facility. Review of Resident #23's care plan dated…

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 maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #10) of 8 observed for infection control. The facility failed to ensure RN C performed hand hygiene and changed gloves during wound care for Resident #10. This failure could place residents at risk for infection and cross contamination. Findings include: Record review of resident #10's Quarterly MDS assessment, dated 03/20/24, reflected a [AGE] year-old male with an admission date of 08/15/23 with diagnoses included peripheral vascular disease, chronic ulcer of unspecified part of left lower leg, and non-pressure chronic ulcer of other part of unspecified foot. Resident #10 had a BIMS of 12 which indicated Resident #10's cognition was moderately impaired. Resident#10 required moderate assistance of one-person physical assistance with dressing, and toileting hygiene. The resident was occasionally incontinent 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 3 residents reviewed for infection. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for infection. Findings included: Review of Resident #1's Face Sheet dated 02/21/24, reflected he was an [AGE] year-old male admitted on [DATE]. His diagnosis included Alzheimer's disease. An observation and interview on 02/21/23 at 11:15 AM with CNA B and CNA A revealed they were preparing to provide Resident #1 with incontinence care. The resident was lying in bed, with his brief already removed. CNA A washed her hands and put on gloves. CNA A cleansed the resident's penis and scrotal area. Resident #1 was assisted 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 revealed the facility failed to make prompt efforts to resolve grievances for 1 of 5 residents (Resident #1) whose records were reviewed for grievances. The facility failed to document, investigate, and respond to Resident#1's family member/visitor's complaint communicated to the Administrator. This deficient practice could contribute to the resident's frustration and feelings of hopelessness. The findings were: A review of Resident #1's electronic sheet face dated undated revealed a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Dysphagia (swallowing difficulties), Vascular parkinsonism (symmetrical lower-body parkinsonism with gait unsteadiness and absence of tremors), and encephalopathy (damage or disease that affects the brain). Resident #1 had a guardian listed. A review of Resident #1's Minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) of 02, indicating…

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 a safe, clean, comfortable, and homelike environment with housekeeping services for a sanitary, orderly, and comfortable interior for 7 of 8 (Residents #3, #4, #18, #20, #22, #25, #35) residents' rooms, 1 of 2 halls and 1 of 1 dining room reviewed for Environment. 1. The facility failed to ensure Residents (#3, #4, #18, #20, #22, #25, #35) had clean bedside tables. 2. The facility failed to ensure Resident #3's wheelchair was safe for him to use. 3. The facility failed to clean the glass door and floor facing east of the enclosed patio area. 4. The facility failed to clean the housekeeping cart and mop buckets used to clean the facility's floors. 5. The facility failed to replace two burgundy linen cart covers located on the 100 hall and clean the bottom of one of the linen carts. These failures could place all residents at risk of cross contamination from dirt and rust resulting in gastro-intestinal and respiratory infections…

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 obtain dental resources and assist the residents with making appointment for 3 of 8 (Residents #4, #22 and #35) residents reviewed for Dental services. The facility failed to assist in providing routine dental services for Residents #4, #22, and #35. This failure could affect all residents by placing them at risk of oral complications with their gums and teeth, causing pain and infections and resulting in a decreased physical and psycho-social well-being. Findings included: 1) Record review of Resident #4's Order Summary Report dated 03/02/23 revealed a 59- year-old male who admitted [DATE] with a doctor's order for Dental Care PRN (When needed) dated 06/24/22. Record review of Resident #4's Care plans dated 03/02/23 revealed no Care Plan for Dental care. Record review of Resident #4's admission MDS assessment dated [DATE] revealed a BIMS score of 13 (Cognitively intact) with no swallowing issues and Oral/Dental status was unchecked for any dental…

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 review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and the resident receives adequate supervision and assistance devices to prevent accidents for two Residents (Resident #2) of six residents reviewed for falls and accidents. This facility failed to place a fall mat beside Resident #2's bed while he was in bed. This failure placed residents at an increased risk of falls, which could lead to injury and pain. Findings Included: Review of Resident #2's undated Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including, muscle weakness, lack of coordination, and mobility problems. Review of Resident #2's care Plan dated 02/16/2023, reflected a risk for falls due to actual falls that occurred on the following noted dates: 10/03/2022, 10/04/2022, 10/08/2022, 10/09/2022, 10/14/2022, 10/18/2022, and 1/22/2023. The care plan reflected goals to help Resident #2 avoid…

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 maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #26 and Resident #43) of 4 residents reviewed for infection control. The facility failed to ensure RN A disinfected the blood pressure cuff in between blood pressure checks for Residents #26, and Resident #43. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident # 26's Quarterly MDS dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Cerebral Vascular Accident (Stroke), Hypertension (high blood pressure) and depression. Review of Resident # 26's Physician Orders dated 05/19/19 reflected, Side Effects- Antipsychotic: chart all appropriate codes- 0-none,…

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.