Inspection Reports for Buckeye Forest at Fairfield Assisted Living
3801 WOODRIDGE BOULEVARD, FAIRFIELD, OH, 45014
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
226% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
66 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Dec 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding improper resident transfers using a mechanical lift and medication administration errors.
Findings
The facility failed to ensure proper transfer of Resident #44 using a mechanical lift, resulting in a fall with minimal harm. Additionally, the facility failed to administer prescribed Methadone medication to Resident #69, resulting in a significant medication error. Both deficiencies were investigated under separate complaint numbers.
Complaint Details
The deficiency related to improper transfer of Resident #44 was investigated under Complaint Number OH00158870. The medication administration deficiency for Resident #69 was investigated under Complaint Number OH00160442.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents were properly transferred using a mechanical lift, resulting in a fall of Resident #44. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide medication per physician orders, resulting in a significant medication error for Resident #69. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for transfers: 3
Residents affected by transfer deficiency: 1
Facility census: 66
Residents reviewed for medication administration: 3
Residents affected by medication deficiency: 1
Facility census: 71
Missed Methadone doses: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding transfer incident and medication administration procedures |
| Certified Nursing Assistant | Certified Nursing Assistant | Admitted transferring Resident #44 alone during mechanical lift transfer |
| Registered Nurse #242 | Registered Nurse | Authored nursing progress note regarding Resident #69 admission |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 4
Sep 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including nutritional care, meal quality and temperature, facility cleanliness, environmental maintenance, and pest control at Ayden Healthcare of Fairfield.
Findings
The facility failed to ensure residents received proper nutrition and dietary supplements as ordered, meals were served at safe and palatable temperatures, the environment was clean and well-maintained, and effective pest control was maintained. Multiple residents experienced weight loss without appropriate interventions, meals were served cold or undercooked, rooms and common areas were dirty and in disrepair, and flies and gnats were present throughout the facility.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Numbers OH00157199 and OH00157500, and Master Complaint Number OH00157500.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide enough food/fluids to maintain residents' health, including failure to provide ordered dietary supplements and obtain weights as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a clean, safe, and comfortable environment for residents, including unclean floors, damaged mattresses, and poor room maintenance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, resulting in presence of flies and gnats in resident rooms and kitchen areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 66
Weight loss: 7.7
Weight loss: 29
Meal temperatures: 80
Meal temperatures: 98
Meal temperatures: 100
Meal temperatures: 135
Residents affected: 5
Residents affected: 65
Residents affected: 17
Residents affected: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian #501 | Registered Dietitian | Confirmed dietary supplements should be provided as ordered and noted concerns with facility staff not implementing recommendations |
| Director of Nursing | Director of Nursing (DON) | Verified residents not receiving proper diet or supplements and confirmed nutritional recommendations had not been implemented |
| LPN #64 | Licensed Practical Nurse | Observed feeding Resident #44 and confirmed no double portions or supplements were provided |
| STNA #8 | State Tested Nursing Assistant | Delivered meals and confirmed no nutritional supplements were present on trays |
| Dietary Supervisor #26 | Dietary Supervisor | Confirmed meal temperatures and presence of flies in kitchen |
| STNA #49 | State Tested Nursing Assistant | Delivered meals and confirmed no dietary supplements present on trays |
| STNA #102 | State Tested Nursing Assistant | Delivered meals and confirmed no dietary supplements present on trays |
| Licensed Practical Nurse #60 | Licensed Practical Nurse | Confirmed dietary supplements were provided by kitchen staff |
| Dietary Aide #21 | Dietary Aide | Verified presence of flies and gnats in kitchen |
| Maintenance Assistant #46 | Maintenance Assistant | Reported only fixing pressing issues and no documentation of repairs |
| Housekeeping Supervisor #31 | Housekeeping Supervisor | Confirmed observations of unclean environment |
| Maintenance Supervisor #48 | Maintenance Supervisor | Confirmed observations of unclean environment |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 17
Sep 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident rights, advance directives, care planning, activities, accident hazards, nutrition, medication management, environment, and pest control.
Findings
The facility was found deficient in multiple areas including failure to provide resolutions to resident council concerns, incomplete advance directive documentation, lack of care conferences, inadequate assistance with activities of daily living, failure to invite residents to activities, inadequate supervision of smokers and fall response, nutritional deficiencies including failure to provide ordered supplements and monitor weights, incomplete medication regimen reviews, inaccurate medication administration documentation, failure to post daily staffing information, poor food quality and temperature control, lack of meal alternatives, unsanitary kitchen conditions, malfunctioning kitchen equipment, unclean resident rooms and common areas, and ineffective pest control.
Complaint Details
This inspection included investigation of complaints OH00157199 and OH00157500. Deficiencies related to nutrition, environment, pest control, and medication management were identified during complaint investigations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Level of Harm - Potential for minimal harm: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure resolutions were provided to residents after resident council meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents had accurate advance directives in place. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to hold care conferences as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received timely and required assistance with meals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were invited and able to participate in activities outside their rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision for residents who smoke and proper storage of smoking materials; failed to provide proper supervision and services following a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure care and services were provided to prevent a decline in nutritional status including failure to provide ordered supplements and obtain weights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure communication between the facility and dialysis center was maintained. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure State Tested Nurse Aides were given a 90-day evaluation. | Level of Harm - Potential for minimal harm |
| Failed to post daily nurse staffing information for residents and visitors to view. | Level of Harm - Potential for minimal harm |
| Failed to ensure accurate documentation of medications administered to residents, including duplicate medication orders and documentation errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals were palatable and served at appropriate temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were able to choose an alternative meal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean and sanitary kitchen environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure kitchen equipment was working properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a clean and maintained environment in resident rooms and common areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure effective pest control was maintained throughout the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 66
Residents affected: 17
Residents affected: 5
Residents affected: 8
Residents affected: 8
Residents affected: 3
Residents affected: 1
Residents affected: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director #11 | Activity Director | Named in resident council and activities findings |
| Administrator | Named in resident council findings | |
| Regional Director of Clinical Services #505 | Regional Director of Clinical Services | Named in advance directive findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including advance directives, fall supervision, medication errors |
| STNA #102 | State Tested Nursing Assistant | Named in ADL assistance and nutrition findings |
| STNA #4 | State Tested Nursing Assistant | Named in ADL assistance and nutrition findings |
| Activity Aide #9 | Activity Aide | Named in activities findings |
| Activity Aide #10 | Activity Aide | Named in activities findings |
| Assistant Director of Nursing #98 | Assistant Director of Nursing | Named in smoking supervision and dialysis communication findings |
| STNA #78 | State Tested Nursing Assistant | Named in smoking supervision findings |
| Dietary Supervisor #26 | Dietary Supervisor | Named in food temperature and nutrition findings |
| LPN #64 | Licensed Practical Nurse | Named in nutrition and medication administration findings |
| STNA #49 | State Tested Nursing Assistant | Named in food alternatives findings |
| Dietary Manager #23 | Dietary Manager | Named in food alternatives findings |
| LPN #60 | Licensed Practical Nurse | Named in nutrition and medication administration findings |
| Registered Dietitian #501 | Registered Dietitian | Named in nutrition findings |
| Human Resource Director #13 | Human Resource Director | Named in STNA evaluation findings |
| Dietary Aide #21 | Dietary Aide | Named in kitchen sanitation and pest control findings |
| Dietary Director #23 | Dietary Director | Named in kitchen sanitation and equipment findings |
| Maintenance Assistant #46 | Maintenance Assistant | Named in environment findings |
| Housekeeping Supervisor #31 | Housekeeping Supervisor | Named in environment findings |
| Maintenance Supervisor #48 | Maintenance Supervisor | Named in environment findings |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 16, 2024
Visit Reason
The document is an annual inspection report for Ayden Healthcare of Fairfield, conducted as part of the facility's regulatory compliance survey.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Aug 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors at the facility.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically one resident (#12) received duplicate doses of morning medications. Additionally, a nurse failed to sign off on medication administration records for multiple residents. The facility's policy on medication administration was not fully followed.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144901.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #12 was given her 6:00 A.M. medications twice by two different nurses due to lack of communication. | Level of Harm - Minimal harm or potential for actual harm |
| LPN #79 failed to sign off on the Medication Administration Records for multiple residents after administering medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 57
Medication administration errors: 1
Residents with unsigned MARs: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #117 | Licensed Practical Nurse | Administered duplicate medications to Resident #12 and authored progress note |
| LPN #58 | Licensed Practical Nurse | Administered medications to Resident #12 without signing MARs or communicating with LPN #117 |
| LPN #79 | Licensed Practical Nurse | Failed to sign off on MARs during medication administration observation |
| LPN #73 | Licensed Practical Nurse | Authored progress note regarding Resident #12's guardian notification |
| Director of Nursing | Director of Nursing | Verified medication administration issues and communication failures |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Aug 4, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to ensure a qualified Activity Director, inadequate pressure ulcer care, and failure to monitor and intervene for residents with significant weight loss and nutritional risk.
Findings
The facility failed to ensure the activities program was directed by a qualified professional, failed to timely identify and treat a resident's pressure ulcer resulting in actual harm, and failed to monitor and intervene for residents with severe weight loss leading to immediate jeopardy. Corrective actions were implemented during the investigation.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00144214.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the services of a qualified Activity Director. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to Resident #14. | Level of Harm - Actual harm |
| Failed to monitor and identify residents with weight loss and failed to ensure appropriate nutritional interventions, resulting in Immediate Jeopardy to Resident #61 and Resident #14. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Facility census: 60
Pressure ulcer size: 2.5
Pressure ulcer size: 2.2
Pressure ulcer size: 3
Pressure ulcer size: 2.3
Weight loss percentage: 36.6
Weight loss percentage: 16.87
Weight loss percentage: 5.9
Weight: 101
Weight: 65
Weight: 247.8
Weight: 231.6
Weight: 221
Weight: 215.6
Weight: 211.4
Weight: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AD #225 | Activities Director | Named in deficiency for not being a qualified Activity Director |
| LPN #815 | Licensed Practical Nurse | Observed wound care and confirmed pressure ulcer details for Resident #14 |
| RD #920 | Registered Dietitian | Involved in nutritional assessments and care plan updates for Residents #14 and #61 |
| DT #925 | Dietetic Technician | Involved in nutritional assessments and care plan updates for Residents #14 and #61 |
| DON | Director of Nursing | Confirmed findings and corrective actions related to weight monitoring and pressure ulcer care |
| MD #935 | Medical Director | Provided medical oversight and was not notified of severe weight loss for Resident #61 |
| STNA #385 | State Tested Nursing Assistant | Provided care and feeding assistance to Resident #61 and reported observations |
| STNA #780 | State Tested Nursing Assistant | Provided care and feeding assistance to Resident #61 and reported observations |
| LPN #725 | Licensed Practical Nurse | Educated on weight monitoring and documentation |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
May 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain a safe, clean, and homelike environment, timely personal care, nutritional interventions for weight loss, pest control, and food safety.
Findings
The facility failed to maintain a clean and safe environment affecting residents #31 and #35, failed to provide timely nail care for Resident #35, did not implement nutritional interventions for significant weight loss in Resident #35, had unsafe food storage and sanitation practices in the kitchen, and lacked an effective pest control program affecting Resident #31 and others.
Complaint Details
This deficiency represents noncompliance discovered in Complaint Number OH00142990.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain a clean and safe homelike environment including debris and dirt in Resident #35's room and missing baseboard. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely nail care for Resident #35, resulting in long fingernails with unknown brown substance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nutritional weight loss interventions were in place for Resident #35 despite significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was stored safely and kitchen sanitation was maintained, including unlabeled and undated food containers and non-functioning dishwasher gauges. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, evidenced by roaches in Resident #31's room and ants in common areas, and lack of pest control documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 65
Weight loss: 22.1
Weight loss percentage: 13.4
Weight loss percentage: 14.9
Unlabeled containers: 15
Uncovered desserts: 12
Pest control visits: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #215 | LPN | Confirmed baseboard missing and debris in Resident #35's room |
| Housekeeper #155 | Housekeeper | Confirmed debris and brown substance in Resident #35's room |
| Licensed Practical Nurse #209 | LPN | Confirmed privacy curtains soiled and killed roaches in Resident #31's room |
| Stated Tested Nurse Aide #119 | STNA | Verified Resident #35 had long fingernails needing trimming |
| Diet Technician #500 | Diet Technician | Reported weight loss concerns for Resident #35 and recommended supplements |
| Medical Director #502 | Medical Director | Unaware of Resident #35's significant weight loss and supplement recommendations |
| Minimum Data Set Nurse #169 | MDS Nurse | Confirmed overlooking supplement order for Resident #35 |
| Director of Nursing | DON | Unaware of Resident #35's weight loss and supplement order status |
| Registered Dietician #502 | RD | Responsible for assessing residents and monitoring high risk residents including Resident #35 |
| Dietary Manager #145 | DM | Confirmed dishwasher gauges not moving and kitchen sanitation issues |
| Dietary [NAME] #127 | Dietary Cook | Confirmed unlabeled and undated food containers in kitchen refrigerator |
| Resident #31 | Resident | Reported frustration with pest control and presence of roaches |
| Licensed Practical Nurse #209 | LPN | Killed roaches in Resident #31's room |
| Registered Nurse #219 | RN | Confirmed ants on food debris in common area |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
May 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to respond appropriately to alleged violations, failure to provide appropriate treatment and care, failure to ensure fall interventions, and failure to maintain a clean and sanitary environment.
Findings
The facility failed to timely report an injury of unknown origin, failed to complete an investigation involving an injury of unknown source, failed to ensure timely transportation for a scheduled appointment resulting in a missed appointment, failed to ensure fall interventions were in place per the plan of care, and failed to maintain a clean and sanitary environment in resident rooms.
Complaint Details
This complaint investigation was conducted under Master Complaint Number OH00142684 and Complaint Number OH00142293. The investigation found multiple deficiencies related to abuse reporting, investigation, treatment, fall prevention, and environmental cleanliness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse related to an injury of unknown origin to the State Survey Agency affecting Resident #62. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to alleged violations by not completing an investigation involving an injury of unknown source affecting Resident #62. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care by not ensuring transportation was arranged timely for a scheduled appointment resulting in a missed appointment for Resident #54. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall interventions were in place per the plan of care for Resident #62. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean and sanitary environment in two resident rooms (#205 and #210). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 65
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #255 | Registered Nurse | Verified observation of Resident #62's bruising and swelling |
| Director of Nursing | Director of Nursing (DON) | Verified reporting and investigation failures related to Resident #62's injury and environmental cleanliness issues |
| Licensed Practical Nurse #235 | Licensed Practical Nurse (LPN) | Verified missed appointment for Resident #54 due to transportation issues |
| State Tested Nurse Aide #199 | State Tested Nurse Aide (STNA) | Verified dirty bathroom floor and walker in resident room |
| Hospital Radiology Employee #599 | Hospital Radiology Employee | Confirmed missed appointment for Resident #54 |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Apr 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and appropriately respond to an allegation of staff to resident verbal/emotional abuse involving Licensed Practical Nurse (LPN) #341 and Resident #58.
Findings
The facility failed to timely report an allegation of verbal/emotional abuse by LPN #341 towards Resident #58 to the State Agency and did not remove the staff member pending investigation. The Administrator considered the behavior inappropriate but not abuse and allowed the staff member to continue working until the incident was reported two weeks later. Resident and witness interviews confirmed the incident occurred.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00141105. The complaint involved failure to timely report and respond to an incident where LPN #341 pulled down her pants and told Resident #58 he could 'kiss her ass' on 03/08/23. The incident was not reported to the State Agency until 03/22/23.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report an allegation of staff to resident verbal/emotional abuse to the State Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove a staff member from the facility pending an investigation of staff to resident verbal/emotional abuse. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Facility census: 63
Complaint Number: OH00141105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #341 | Licensed Practical Nurse | Named in verbal/emotional abuse incident involving Resident #58 |
| Administrator | Facility Administrator who failed to timely report the incident and did not remove the staff member pending investigation | |
| Long-Term Care Ombudsman #500 | Long-Term Care Ombudsman | Reported the incident to the Administrator and advised it was reportable |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Mar 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to maintain a clean and sanitary home-like environment.
Findings
The facility failed to maintain cleanliness in multiple areas including hallways, dining area, and resident rooms, with visible dirt, dried red spots, and food debris. The Administrator acknowledged the issues and stated that floor maintenance was ongoing but incomplete.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00140583.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a clean and sanitary home-like environment with dirt crusted on floors, dried red spots, and food debris in resident rooms and common areas. | Level of Harm - Potential for minimal harm |
Report Facts
Residents Affected: 63
Length of dirt crust: 6
Width of dirt crust: 10
Time of observations: 9.1
Time of observations: 9.15
Time of observations: 11.35
Time of interview: 11.57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding dirty floors and red spots in hallway | |
| Registered Nurse | Interviewed regarding black dirt under cabinetry and appliances in dining area | |
| Licensed Practical Nurse | Interviewed regarding dirty floor and debris in Resident #58's room | |
| Administrator | Interviewed regarding floor maintenance and cleaning delays |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 7
Oct 28, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely notification to residents, representatives, and the Ombudsman before transfer or discharge, including appeal rights, and other related concerns.
Findings
The facility failed to provide timely notification of hospital transfers and discharges to residents, representatives, and the Ombudsman. Additionally, deficiencies were found in fall prevention interventions, nutrition monitoring and weight documentation, medication storage and administration, menu preparation and adherence, therapeutic diet provision, and food safety related to outside food labeling and storage.
Complaint Details
The complaint investigation focused on failure to provide timely notification to residents, representatives, and the Ombudsman regarding transfers and discharges, as well as other care and safety concerns including falls, nutrition, medication management, and food safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide timely notification to residents, representatives, and Ombudsman before transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure care planned interventions were implemented to prevent falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure complete and accurate weight documentation and timely re-weighing for residents with significant weight changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep all medications in locked compartments except when administered by licensed nursing staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prepare menus for mechanically altered diets in advance, have menu changes reviewed and approved by a Registered Dietitian, and follow menus including portion sizes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received therapeutic diets as prescribed by the attending physician. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident food brought in from outside was properly labeled, dated, and stored to prevent food borne illness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 65
Residents affected by notification deficiency: 4
Residents reviewed for discharge: 5
Residents reviewed for falls: 24
Residents affected by fall prevention deficiency: 1
Residents reviewed for nutrition: 8
Residents affected by nutrition weight documentation deficiency: 2
Residents affected by medication storage deficiency: 1
Residents affected by menu preparation deficiency: 4
Residents affected by therapeutic diet deficiency: 1
Residents affected by food labeling and storage deficiency: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #133 | Licensed Practical Nurse | Named in medication administration finding for leaving medications with resident without observation |
| DTR #19 | Dietetic Technician, Registered | Named in nutrition weight monitoring and menu review findings |
| DON | Director of Nursing | Interviewed regarding notification, weight monitoring, and food tray observations |
| DM #12 | Dietary Manager | Interviewed regarding menu preparation and food substitutions |
| RD #18 | Registered Dietitian | Interviewed regarding diet recommendations and menu approvals |
| STNA #115 | State Tested Nurse Aide | Named in fall incident report |
| Administrator | Interviewed regarding notification failures | |
| Social Services Designee #38 | Interviewed regarding notification practices |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 12
Jan 17, 2019
Visit Reason
The inspection was conducted based on complaints and observations related to residents' rights, grievance policies, notification failures, care planning, medication storage, fall investigations, infection control, and equipment safety at Ayden Healthcare of Fairfield.
Findings
The facility failed to post residents' rights and ombudsman contact information, serve dinner in a homelike environment, establish a grievance policy, notify the ombudsman of hospital transfers, update PASARR and care plans, ensure accurate advance directives, investigate falls, properly store medications, maintain infection control documentation, and keep essential equipment safe.
Complaint Details
The complaint investigation revealed multiple deficiencies affecting residents' rights, care planning, medication management, fall investigations, infection control, and equipment safety.
Severity Breakdown
Level of Harm - Potential for minimal harm: 3
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to post Residents' Rights and Ombudsman contact information. | Level of Harm - Potential for minimal harm |
| Failed to serve dinner in a homelike environment by not removing china plates from trays. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish a grievance policy and designate a grievance official. | Level of Harm - Potential for minimal harm |
| Failed to notify the Office of the State Long-Term Care Ombudsman in writing upon resident hospital transfers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update PASARR for a resident with new diagnosis of psychotic disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a care plan for a resident's tracheostomy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update care plans to reflect residents' current code status and involve residents in care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate advance directives in medical records. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate two falls for a resident and improperly stored prescription medication in a resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to discard undated and expired injectable medications and expired insulin appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide documentation related to Legionella assessment, control plan, and monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident's wheelchair was in safe working condition; missing arm rest pad. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 91
Residents affected: 16
Residents affected: 22
Residents reviewed: 20
Residents reviewed: 3
Residents reviewed: 5
Residents reviewed: 3
Medication vials: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director #208 | Activity Director | Denied informing residents of grievance procedures and residents' rights complaint process |
| Regional Director of Clinical Operations #400 | Regional Director of Clinical Operations | Confirmed lack of Ombudsman contact information and grievance designee |
| Social Worker #202 | Licensed Social Worker | Verified PASARR not updated and lack of grievance designee |
| Director of Nursing | Director of Nursing | Confirmed care plan deficiencies and fall investigation issues |
| Registered Nurse #15 | Registered Nurse | Confirmed code status documentation issues |
| Registered Nurse #600 | Registered Nurse | Confirmed care plan and advance directive discrepancies |
| Licensed Practical Nurse #70 | Licensed Practical Nurse | Verified improper medication storage in resident room |
| Registered Nurse #194 | Registered Nurse | Confirmed expired medication storage |
| Licensed Practical Nurse #38 | Licensed Practical Nurse | Confirmed expired insulin storage |
| Regional Director of Operations #500 | Regional Director of Operations | Verified lack of Legionella documentation and wheelchair safety issue |
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