Inspection Reports for Fairmont Rehabilitation and Healthcare Center LLC
130 KAUFMAN DRIVE, WV, 26554
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 4, 2023
Visit Reason
The visit was conducted as a complaint investigation survey concluding on 09/11/2023, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
The facility, Fairmont Healthcare and Rehabilitation Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Complaint Details
The complaint investigation survey concluded on 09/11/2023, and the facility was found in substantial compliance with previously cited deficient practices.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay in the facility. | Level C |
Report Facts
Event ID: 860Y11
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Sep 11, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Fairmont Healthcare and Rehabilitation on 09/11/23 based on Complaint #28795.
Findings
The facility was found deficient in ensuring the resident call system was accessible to residents in bed, nurse staffing information was posted and accessible to residents and visitors, and comprehensive care plans for fall prevention interventions were not fully implemented for some residents.
Complaint Details
Complaint #28795 was substantiated with related deficiencies.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to ensure the call system was accessible to residents while in their bed; six residents had call systems on the floor and not within reach. | Level D |
| The facility failed to ensure nurse staffing information was posted in an accessible location to residents and visitors. | Level E |
| The facility failed to implement the care plans for three residents who were care planned for the potential for falls, specifically ensuring call bells were within reach as an intervention. | Level D |
Report Facts
Residents with call systems not within reach: 6
Residents with care plans for falls but call bells not within reach: 3
Facility census: 109
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | HS #52 who identified residents with call bells not within reach | |
| Director of Nursing | Discussed findings and responsible for corrective actions | |
| Admissions Director | Observed nurse staffing folder lacking posted information | |
| Staffing Coordinator | Responsible for posting nurse staffing information | |
| Registered Nurse Assessment Coordinator | Conducted audit of residents' fall care plans |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 31, 2023
Visit Reason
The document is a plan of correction submitted in response to previously cited deficiencies during a survey concluding on 07/20/2023, accepted in lieu of an onsite revisit.
Findings
The facility is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and rules governing resident conduct as required by 483.10(b)(5)-(10), including providing notice of Medicaid benefits and charges. | Level C |
Report Facts
Event ID: 860Y11
Provider/Supplier Identification Number: 515189
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 5
Jul 20, 2023
Visit Reason
The inspection was conducted as an unannounced focused infection control survey and complaint investigation to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to provide scheduled showers to dependent residents, inaccurate assessment and staging of pressure ulcers, inaccurate Minimum Data Set (MDS) documentation, failure to maintain accurate resident weights and physician orders for wounds, and failure to serve food in accordance with food safety standards.
Complaint Details
Complaint #28632 was investigated and found unsubstantiated; however, unrelated deficiencies were cited during the complaint investigation survey.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure dependent residents received scheduled showers as per care plans. | SS=D |
| Failure to accurately assess and stage pressure ulcers for residents #80, #6, and #107. | SS=D |
| Failure to complete accurate Minimum Data Set (MDS) assessments reflecting pressure ulcers for residents #80 and #6. | SS=D |
| Failure to maintain accurate resident weights and physician orders for wound care, including missing wound site in orders. | SS=D |
| Failure to serve food in accordance with professional food safety standards; uncovered corn bread and brownies were distributed to residents. | SS=E |
Report Facts
Facility census: 110
Resident shower opportunities: 9
Resident shower opportunities: 5
Resident shower schedule: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.8
Pressure ulcer measurements: 2.5
Weight difference: 31.3
Weight difference: 37.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed deficiencies related to shower schedules, pressure ulcer staging, and wound orders. | |
| Certified Dietary Manager | Interviewed regarding uncovered food items served to residents. | |
| Nursing Home Administrator | Verified weight re-weighing policy and confirmed weight discrepancies for Resident #103. |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 14
May 10, 2023
Visit Reason
An unannounced annual recertification and complaint survey was conducted at Fairmont Healthcare and Rehabilitation Center from 05/08/23 to 05/10/23, including review of residents' clinical records, interviews, and facility documentation.
Findings
The facility had multiple deficiencies including inaccurate Minimum Data Set assessments, failure to respond to medication regimen reviews, unsafe medication storage, infection prevention and control lapses, incomplete care plans, failure to provide emergency respiratory equipment, incomplete arbitration agreement explanations, incomplete and inaccurate Physician Orders for Scope of Treatment (POST) forms, failure to report serious bodily injuries timely, incomplete medical records, improper medication storage temperature logs, and failure to provide special eating equipment as ordered.
Severity Breakdown
SS=D: 9
SS=E: 4
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| 483.20(g) Accuracy of Assessments - Facility failed to have an accurate Minimum Data Set (MDS) for Resident #51 regarding an active diagnosis of right femur fracture. | SS=D |
| 483.45(c)(1)(2)(4)(5) Drug Regimen Review - Physician and/or designee failed to respond to pharmacist's medication regimen review recommendations for Resident #19. | SS=D |
| 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices - Facility failed to ensure resident environment was free of accident hazards; unsecured medication at bedside for Resident #31. | SS=E |
| 483.80 Infection Prevention & Control - Facility failed to maintain infection prevention and control program; residents did not have hand hygiene prior to meals, improper infection control during medication pass, and improper linen handling. | SS=F |
| 483.21(b)(1) Develop/Implement Comprehensive Care Plan - Facility failed to implement care plan intervention for Resident #102; Ambu bag not at bedside as required. | SS=D |
| 483.70(n) Binding Arbitration Agreements - Facility failed to ensure arbitration agreement was explained in a form and manner residents or representatives could understand for Residents #98 and #205. | SS=E |
| 483.25(i) Respiratory/Tracheostomy Care and Suctioning - Facility failed to provide respiratory equipment properly stored for Residents #19 and #355; oxygen tubing not dated for Resident #4. | SS=D |
| 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision - Facility failed to revise care plan to reflect changes in respiratory care for Resident #19. | SS=D |
| 483.25(g)(4)(5) Tube Feeding Management/Restore Eating Skills - Facility failed to ensure enteral feeding care was provided according to professional standards; Glucerna bottle not dated for Resident #357. | SS=D |
| 483.15(d)(1)(2) Notice of Bed Hold Policy Before/Upon Transfer - Facility failed to provide bed hold policy notice during transfers for Resident #94. | SS=D |
| 483.25 Quality of Care - Facility failed to ensure pain medication was administered per physician order for Resident #37 and failed to date/sign medication patch for Resident #27. | SS=D |
| 483.20(f)(5); 483.70(i)(1)-(5) Resident Records - Identifiable Information - Facility failed to maintain complete and accurate medical records including incomplete Physician Orders for Scope of Treatment (POST) forms for multiple residents. | SS=E |
| 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals - Facility failed to ensure medication refrigerator temperature logs were complete and up-to-date. | SS=E |
| 483.60(g) Assistive Devices - Eating Equipment/Utensils - Facility failed to provide special eating equipment as ordered for Resident #2. | SS=D |
Report Facts
Facility census: 105
Deficiency count: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #22 | Registered Nurse | Verified medication refrigerator temperature logs incomplete and respiratory equipment storage issues |
| LPN #134 | Licensed Practical Nurse | Observed medication administration and documented fall notification |
| Administrator | Facility administrator involved in interviews and acknowledged errors | |
| Director of Nursing | Director of Nursing | Involved in audits, education, and interviews regarding multiple deficiencies |
| Social Worker #59 | Social Worker | Interviewed regarding POST form deficiencies and resident representative communication |
| Admissions Coordinator #96 | Admissions Coordinator | Unable to explain arbitration agreement |
| Dietary Manager | Dietary Manager | Responsible for kitchen audits and education on food safety and special eating equipment |
Inspection Report
Annual Inspection
Deficiencies: 0
May 10, 2023
Visit Reason
The inspection was conducted as an annual recertification/licensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the regulatory requirements, with plans of correction and credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were addressed satisfactorily.
Inspection Report
Life Safety
Deficiencies: 0
May 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Sep 7, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at Fairmont Healthcare and Rehabilitation Center from August 6-7, 2022.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaints #27289 and #27322 were unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #27289 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27322 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Census: 98
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Jun 1, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at Fairmont Healthcare and Rehabilitation Center from May 31 to June 1, 2022.
Findings
The facility was found to be in substantial compliance with applicable federal and state regulations. Complaint #26844 was unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #26844 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Census: 108
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 29, 2022
Visit Reason
The visit was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Deficiencies: 0
Mar 23, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with Federal, State, and local Emergency Preparedness requirements based on documentation and staff interviews.
Findings
The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Routine
Census: 108
Deficiencies: 4
Feb 15, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with NFPA standards for fire alarm system testing and maintenance, sprinkler system installation, electrical equipment testing and maintenance, and gas equipment qualifications and training.
Findings
The facility failed to maintain the fire alarm system with emergency backup batteries, had sprinkler heads installed too close to light fixtures, did not have current electrical safety testing for nebulizers, and lacked documentation of personnel training for medical gas equipment handling. These deficiencies were acknowledged by facility leadership and corrective actions were planned.
Severity Breakdown
SS=F: 2
SS=C: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide evidence of maintaining the Fire Alarm System with emergency backup batteries in accordance with NFPA 101 and 72. | SS=F |
| Sprinkler heads located less than twelve inches from light fixtures, exceeding allowable distance per NFPA 13. | SS=F |
| Failed to maintain testing and maintenance requirements for fixed and portable patient-care electrical equipment; three nebulizers lacked current electrical safety inspection stickers or documentation. | SS=C |
| Failed to ensure personnel received appropriate qualifications and training for medical gas equipment handling and maintenance. | SS=C |
Report Facts
Facility census: 108
Number of nebulizers without electrical safety inspection: 3
Number of sprinkler heads improperly located: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Discussed deficiencies and responsible for corrective actions and audits | |
| Plant Operations Director | Discussed deficiencies at time of discovery and exit | |
| Administrator | Discussed deficiencies at time of exit | |
| Regional Director of Plant Operations | Provided re-education on NFPA standards to Director of Maintenance | |
| Nursing Home Administrator | Conducted audit of portable patient-care equipment and ensured staff education | |
| Regional Director of Operations | Provided re-education on NFPA 99 to Director of Maintenance |
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 19
Feb 14, 2022
Visit Reason
An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Fairmont Healthcare and Rehabilitation Center from February 14-16, 2022.
Findings
The survey identified multiple deficiencies including failure to ensure residents' dignity and privacy, inadequate accommodations during room changes, failure to display survey results accessibly, incomplete advance directive documentation, unsafe and unsanitary environment conditions, insufficient nursing staff and medication administration issues, infection control lapses, and failure to properly notify families of COVID-19 cases.
Complaint Details
Multiple complaints were investigated during the survey. Complaint #25513, #25678, and #26013 were substantiated with related deficiencies cited. Complaint #25840 and #25641 were unsubstantiated with no deficiencies cited.
Severity Breakdown
SS=C: 1
SS=D: 8
SS=E: 8
Deficiencies (19)
| Description | Severity |
|---|---|
| Residents' indwelling urinary catheter bags lacked privacy covers and Resident #55 was left uncovered in a hallway bed. | SS=C |
| Resident #55 was left in the hallway without call light or linens during room change. | SS=D |
| Facility failed to display most recent State inspection survey results in an accessible area. | SS=D |
| Facility failed to ensure advance directives were clearly documented and communicated for residents #411, #44, and #106. | SS=E |
| Resident #106's bed linens were soiled, bathroom was unclean with leaking toilet sprayer, and insufficient washcloths were available. | SS=E |
| Resident #86's grievance about nursing assistant was not documented or resolved timely. | SS=D |
| Facility failed to report alleged abuse/neglect involving Resident #261 to proper authorities within required timeframe. | SS=D |
| Discharge Minimum Data Set (MDS) assessment was not completed timely for Resident #2. | SS=D |
| Comprehensive care plans were incomplete or not revised timely for Residents #93, #42, #410, #5, and #90. | SS=D |
| Facility failed to provide sufficient nursing staff to ensure call lights were answered timely and room changes completed timely affecting Residents #107, #55, #212, and #69. | SS=E |
| Medications were administered late and narcotic counts were inaccurate affecting Residents #76, #8, #44, and #83. | SS=E |
| Facility failed to maintain infection prevention and control program; hand hygiene was inadequate and catheter care was improper for Residents #102, #52, #46, #39, and #95. | SS=E |
| Facility failed to ensure residents receiving dialysis were monitored post-treatment and communication with dialysis center was incomplete for Resident #86. | SS=D |
| Facility failed to maintain kitchen in a safe and sanitary manner including dirty drip pan, food debris on floors, missing floor tiles, and undated flour bin. | SS=E |
| Facility failed to implement an antibiotic stewardship program with appropriate protocols and monitoring for Residents #317, #38, #49, #314, #45, #315, and #27. | SS=E |
| Facility failed to vaccinate eligible residents with influenza and pneumococcal vaccines for Residents #102, #3, #313, #8, and #24. | SS=E |
| Facility failed to provide a safe, clean environment; broken outlet cover with exposed wiring and large hole in over-the-bed table observed in Resident #8's room. | SS=D |
| Facility failed to ensure staff have competencies to provide care to resident with psychosocial disorders; Resident #22 was tearful and care plan interventions were not implemented. | SS=D |
| Facility failed to notify residents, their representatives, and families by 5 p.m. the next calendar day following occurrence of each confirmed COVID-19 infection. | SS=E |
Report Facts
Facility census: 108
Deficiency count: 17
Medication late administration: 5
Missing washcloths: 60
Missing narcotic pill: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in findings related to Resident #55 dignity and call light access |
| LPN #14 | Licensed Practical Nurse | Named in findings related to Resident #102 catheter care and Resident #55 room placement |
| RN #27 | Registered Nurse | Named in medication administration and catheter removal findings |
| NA #47 | Certified Nursing Assistant | Named in catheter care observation |
| IP #26 | Infection Preventionist | Named in findings related to antibiotic stewardship and infection control |
| Administrator | Named in multiple findings related to survey results posting, complaint reporting, COVID-19 notification, and general oversight | |
| Director of Nursing | Named in multiple findings related to care plan, medication administration, infection control, and quality assurance | |
| Social Worker #36 | Social Worker | Named in findings related to advance directives and grievance follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 6, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #24015, including a focused infection control survey.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. Plans of correction and credible evidence were accepted in lieu of an onsite revisit, concluding the complaint investigation and focused infection control survey.
Complaint Details
Complaint reference number 24015 was investigated, and the facility was found to be in substantial compliance with previously cited deficient practices.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 5, 2020
Visit Reason
An unannounced complaint survey was conducted at Fairmont Health and Rehabilitation Center on October 5, 2020.
Findings
Complaint #24539 was unsubstantiated with no unrelated deficiencies cited.
Complaint Details
Complaint #24539 was unsubstantiated with no unrelated deficiencies cited.
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Aug 11, 2020
Visit Reason
An unannounced complaint survey was conducted at Fairmont Healthcare and Rehabilitation on August 11-13, 2020, triggered by complaint #24015 which was substantiated.
Findings
The facility was found deficient in food procurement and sanitary storage practices, as well as infection prevention and control, including failure to assist residents with hand hygiene before meals. Specific issues included opened, undated, and unsealed food items stored improperly and dirty ice chest equipment, as well as staff not assisting residents with hand hygiene before meals.
Complaint Details
Complaint #24015 was substantiated with related deficiencies cited at F812 (food procurement and sanitary storage) and F880 (infection prevention and control).
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to store foods in a safe and sanitary manner; opened, undated, and unsealed items were stored in the freezer and the ice chest and its cart were dirty. | SS=D |
| Failed to establish and maintain an infection prevention and control program to prevent transmission of communicable diseases and infections; staff did not assist residents with hand hygiene before meals. | SS=E |
Report Facts
Facility census: 103
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #52 | Certified Nursing Assistant | Observed not assisting residents with hand hygiene before meals; later educated and observed assisting with hand hygiene. |
| LPN #16 | Licensed Practical Nurse | Confirmed observations regarding food storage and acknowledged need for cleaning ice chest and cart. |
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 107
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 6, 2020
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Life Safety
Deficiencies: 0
Feb 11, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to evaluate compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the NFPA 101 Life Safety Code, 2012, and met all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 12
Feb 10, 2020
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Fairmont Healthcare and Rehabilitation Center from 02/10/20 through 02/13/20.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, care plan development and implementation, accuracy of assessments, quality of care, infection control, medication administration, and immunization procedures. Specific issues included failure to respect resident privacy, failure to honor resident choices, inaccurate assessments, incomplete care plans, improper medication administration, and inadequate infection prevention practices.
Severity Breakdown
SS=D: 10
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident received respect and dignity regarding staff entering a resident's room without asking or receiving permission to enter. | SS=D |
| Facility failed to honor a resident's choice regarding shower frequency. | SS=D |
| Facility failed to ensure accurate completion of Minimum Data Set (MDS) assessment at discharge. | SS=D |
| Facility failed to develop and/or implement comprehensive care plans related to nutrition, activities of daily living, and accidents for multiple residents. | SS=E |
| Facility failed to ensure resident participation in care plan development and failed to revise care plan related to discharge planning. | SS=D |
| Facility failed to ensure residents received treatment and care in accordance with professional standards, comprehensive care plans, and residents' choices, including medication administration and blood pressure monitoring orders. | SS=E |
| Facility failed to ensure resident environment was free of accident hazards and adequate supervision was provided to prevent accidents. | SS=D |
| Facility failed to ensure food accommodated resident allergies and preferences. | SS=D |
| Facility failed to dispose of garbage and refuse properly, with debris scattered around outdoor dumpsters. | SS=D |
| Facility failed to maintain complete and accurate medical records, including inconsistent code status documentation and incomplete medication orders. | SS=D |
| Facility failed to establish and maintain an infection prevention and control program to prevent development and transmission of infections; a barrier was not used between resident's bedside table and inhaler medications. | SS=D |
| Facility failed to provide education and screening related to influenza immunization prior to administration. | SS=D |
Report Facts
Facility census: 112
Resident weight: 338.7
Deficiency count: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA#44 | Nurse Aide | Named in finding related to resident #65 fall and assistance during transfers |
| RN#5 | Registered Nurse | Responsible for care plan development and named in findings related to care plan deficiencies |
| LPN#13 | Licensed Practical Nurse | Named in medication administration deficiency related to inhaler handling |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 30, 2019
Visit Reason
The inspection was conducted as a complaint investigation survey based on complaints referenced as ##22982 and 22910, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by the accepted plans of correction.
Complaint Details
Complaint reference numbers ##22982 and 22910 were investigated; the facility was found in substantial compliance with previously cited deficiencies.
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Nov 7, 2019
Visit Reason
An unannounced complaint survey was conducted at Fairmont Healthcare and Rehabilitation Center from 2019-11-04 to 2019-11-07. The investigation was triggered by complaints #22910 and #22982, with #22982 substantiated and related deficiencies cited.
Findings
The facility failed to ensure all residents received treatment and care consistent with professional standards related to ongoing monitoring of pressure wounds. Specifically, weekly pressure ulcer wound measurements and assessments were not consistently obtained and documented for Resident #7, resulting in gaps of up to thirteen days without RN wound assessments or measurements.
Complaint Details
Complaint #22910 was unsubstantiated with no deficiencies cited. Complaint #22982 was substantiated with a related deficiency cited regarding pressure ulcer care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure weekly registered nurse assessments and measurements of pressure ulcers, evidenced by missing weekly wound measurements for Resident #7 over multiple weeks in June 2019. | SS=D |
Report Facts
Resident census: 108
Days without RN wound assessment: 13
Pressure ulcer dimensions: 4
Pressure ulcer dimensions: 6
Pressure ulcer dimensions: 0.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Assessed and measured Resident #7's pressure wound on 06/13/19 |
| RN #16 | Registered Nurse / Assistant Director of Nursing | Wound nurse in June 2019 who assessed and measured Resident #7's pressure wound on 06/26/19 and provided interview |
| LPN #34 | Licensed Practical Nurse | Documented assessments without measurements for Resident #7's pressure wound in June 2019 |
| Director of Nursing | Director of Nursing | Provided interview regarding wound measurement practices on 11/06/19 |
| Administrator | Administrator | Provided facility wound care policy and interview on 11/07/19 |
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 19
Jan 31, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Fairmont Healthcare and Rehabilitation Center from 01/28/19 through 01/31/19.
Findings
The facility was found deficient in multiple areas including resident rights, dignity during care and dining, reasonable accommodations, self-determination, safe environment, transfer and discharge documentation, accuracy of assessments, care planning, medication management, infection control, and quality assurance processes. Specific issues included failure to serve meals simultaneously, call lights out of reach, undated inhalers, incomplete discharge summaries, delayed lab testing for anticoagulation, improper catheter care, and inadequate pain management documentation.
Severity Breakdown
SS=E: 6
SS=D: 8
SS=C: 1
SS=F: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Residents were not served meals at the same time, causing dignity concerns. | SS=E |
| Resident call lights were not always within reach. | SS=D |
| Resident choice was not honored for meal times. | SS=D |
| Wheelchair arm rests were torn and caused injury risk. | SS=D |
| Incomplete discharge summary for Resident #103. | SS=D |
| Inaccurate Minimum Data Set (MDS) assessments for falls and medications. | SS=D |
| Care plans lacked individualized measurable goals and interventions for several residents. | SS=D |
| Failure to obtain PT/INR lab tests as ordered for residents on warfarin. | SS=E |
| Failure to ensure medications were available for Resident #153. | SS=E |
| Resident #28 received extra doses of antipsychotic medication without proper order. | SS=D |
| Metered-dose inhalers were not labeled with date opened. | SS=D |
| Delay in obtaining STAT ultrasound for Resident #153. | SS=D |
| Food portions and temperatures were not consistent with menu and resident preferences. | SS=E |
| Quality Assurance and Process Improvement (QAPI) committee failed to have Medical Director attend quarterly meetings. | SS=C |
| Laundry room lacked separation between clean and soiled areas; respiratory equipment and wound supplies were improperly stored; medication contamination risk observed. | SS=F |
| Resident #47 was not assessed or care planned for self-removal of dialysis dressing. | SS=D |
| Resident #66 catheter tubing was not anchored properly. | SS=D |
| Resident #67 received oxygen at 10L via non-rebreather mask without physician order. | SS=D |
| Facility failed to consistently assess effectiveness of PRN pain medication for residents #53 and #153. | SS=D |
Report Facts
Facility census: 108
Deficiencies cited: 16
Vitamin B-12 dosage: 2000
Warfarin dosage: 9
Oxygen liters: 10
Barbecue meat portion: 3
Food temperatures: 129.7
Food temperatures: 53.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Noted inhalers were not dated and administered Vitamin B-12 dosage discrepancy |
| RN #11 | Registered Nurse, MDS Coordinator | Acknowledged MDS inaccuracies and lack of dental consult for Resident #3 |
| RN #75 | Registered Nurse Unit Manager | Confirmed missing PT/INR labs and oxygen order clarification |
| LPN #65 | Licensed Practical Nurse | Observed resident removing dialysis dressing, confirmed PT/INR machine error |
| Consultant Dietitian #121 | Consultant Dietitian | Corrected food portioning and serving utensil use |
| Maintenance Supervisor #115 | Maintenance Supervisor | Acknowledged laundry room deficiencies |
| Director of Nursing | Director of Nursing | Provided multiple clarifications and education on deficiencies |
| Administrator | Facility Administrator | Responsible for QAPI committee and acknowledged Medical Director attendance issue |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 31, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were corrected.
Inspection Report
Life Safety
Deficiencies: 0
Jan 29, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
May 30, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the regulatory requirements, with plans of correction and credible evidence accepted in lieu of an onsite revisit. The facility is in substantial compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 8
Apr 12, 2018
Visit Reason
An unannounced annual recertification and relicensure survey was conducted at Fairmont Health and Rehabilitation Center from 04/09/18 through 04/12/18 to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to maintain respiratory equipment safely and cleanly, inaccurate resident assessments, incomplete and outdated comprehensive care plans, lack of individualized resident-centered activity programs especially for hospice residents, incomplete medical records for hospice care, ineffective antibiotic stewardship program, breaches in infection control practices, and failure to update care plans after hospitalizations.
Severity Breakdown
SS=E: 2
SS=D: 3
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to maintain respiratory equipment in a safe and sanitary manner, including dirty nebulizer cases, dusty oxygen concentrator filters, and lack of maintenance records. | SS=E |
| Failure to conduct accurate comprehensive assessments for residents, including missing psychiatric diagnoses and incorrect prognosis coding. | SS=D |
| Failure to develop and implement comprehensive, person-centered care plans with measurable goals and interventions reflecting current resident needs. | SS=E |
| Failure to provide an ongoing resident-centered activities program meeting the interests and needs of hospice residents. | SS=D |
| Failure to maintain complete and accurate medical records reflecting hospice care services and physician orders. | SS=D |
| Failure to maintain an effective Quality Assessment and Assurance (QAA) committee that identifies and acts upon quality deficiencies, including lack of a comprehensive antibiotic stewardship program. | SS=F |
| Failure to establish and maintain an effective infection prevention and control program, including breaches in infection control practices such as catheter bags lying on the floor and improper medication handling. | SS=F |
| Failure to implement an antibiotic stewardship program with protocols and monitoring to ensure appropriate antibiotic use. | SS=F |
Report Facts
Survey sample size: 45
Facility census: 106
Residents with infections on antibiotics: 6
Residents with infections on antibiotics: 15
Residents with infections on antibiotics: 19
Residents with infections on antibiotics: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #70 | Clinical Reimbursement Director | Verified inaccurate resident assessment for Resident #27. |
| Employee #51 | Registered Nurse | Verified current physician's orders for Resident #83 did not include hospice care services. |
| Employee #67 | Infection Control Nurse / Registered Nurse | Confirmed facility was not utilizing a standard assessment tool for residents suspected of infection and acknowledged infection control breaches. |
| Employee #124 | Registered Respiratory Therapist | Reported oxygen concentrators should be checked yearly and external filters rinsed weekly. |
| Employee #28 | Licensed Practical Nurse | Reported Resident #23's inappropriate behaviors and confirmed Resident #51's hospitalization details. |
| Employee #89 | Social Services Director | Provided information on Resident #23's behaviors and Resident #39's psychotropic needs. |
| Employee #9 | Nurse Aide | Reported Resident #11's decline and dependency. |
| Employee #47 | Activities Director | Reported lack of individualized activities for Resident #11. |
| Employee #16 | Licensed Practical Nurse | Observed breaching infection control during medication pass. |
| Employee #40 | Licensed Practical Nurse | Observed catheter bag lying on floor for Resident #57. |
Inspection Report
Census: 106
Deficiencies: 2
Apr 10, 2018
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 standards for illumination of means of egress and NFPA 99 standards for electrical equipment testing and maintenance, including patient care related electrical equipment.
Findings
The facility failed to maintain proper illumination of means of egress as required by NFPA 101, with exit discharge areas having only a single light bulb. Additionally, the facility failed to maintain testing and maintenance of patient care related electrical equipment in accordance with NFPA 99.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain illumination of means of egress in accordance with NFPA 101; exit discharge areas contained only a single light bulb. | SS=C |
| Failed to maintain testing and maintenance requirements for patient care related electrical equipment in accordance with NFPA 99. | SS=C |
Report Facts
Facility census: 106
Deficiency completion date: May 2, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to corrective actions for lighting and electrical equipment testing deficiencies | |
| Plant Operations Director | Verified findings related to lighting and electrical equipment testing deficiencies | |
| Administrator | Verified findings at time of exit |
Inspection Report
Deficiencies: 1
Sep 29, 2017
Visit Reason
The document is a statement of deficiencies and plan of correction for Fairmont Rehabilitation and Healthcare Center LLC, detailing regulatory compliance related to resident rights and facility obligations.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by federal regulations.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 2
Sep 25, 2017
Visit Reason
An unannounced revisit was conducted at Fairmont Health and Rehabilitation Center from 09/25/17 to 09/27/17 for the Quality Indicator and Licensure Surveys concluding on 06/30/17. The revisit was to verify correction of previous deficiencies.
Findings
The facility remained out of compliance with medication storage and pharmaceutical service requirements related to the safe and effective use of medications, specifically insulin pens and vials that were open beyond manufacturer recommended timeframes or lacked proper dating. The facility failed to ensure proper dating and disposal of multi-dose insulin pens and vials, as well as purified protein derivative (PPD) vials, which could negatively impact medication safety and potency.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure safe and effective use of medications; insulin pens and vials were open beyond manufacturer recommended timeframes or lacked proper dating. | SS=D |
| Failure to maintain accurate drug records and proper labeling/storage of drugs and biologicals; insulin pens and multi-dose vials lacked proper dating and labeling. | SS=E |
Report Facts
Facility census: 112
Revisit sample size: 15
Insulin pen disposal dates: Resident #54 Humalog insulin pen disposed on 09/22/17; Resident #99 Lantus insulin disposed on 09/23/17; Resident #115 Novolog pen disposed on 09/25/17
Audit frequency: 3
Medication use timeframe: 28
Medication use timeframe Tresiba: 56
PPD vial discard timeframe: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication storage room and acknowledged expired insulin pens and vials |
| LPN #2 | Licensed Practical Nurse | Observed medication storage room and acknowledged expired insulin pens and vials |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage deficiencies and corrective actions |
| Staff Development Coordinator/Designee | Re-educated licensed nurses on medication storage and expiration dating |
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 16
Jun 30, 2017
Visit Reason
Unannounced annual off hours Quality Indicator Survey, State Licensure Survey, and a Complaint Survey conducted from June 20, 2017 through June 30, 2017, including an extended survey from June 29 to June 30, 2017.
Findings
The survey identified multiple deficiencies including failure to maintain an approved surety bond, inadequate grievance resolution, verbal abuse of a resident, failure to maintain resident dignity during dining, failure to maintain a safe and homelike environment, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, inadequate infection control practices, and incomplete medical records.
Complaint Details
Complaint Reference #18102 was substantiated with related deficiencies cited at F166 and F323.
Severity Breakdown
SS=E: 7
SS=D: 6
SS=F: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to have an approved surety bond to ensure security of residents' personal funds. | SS=E |
| Failure to ensure prompt efforts to resolve grievances and complaints in a timely manner. | SS=E |
| Resident #44 was verbally abused by a nursing assistant; resident exhibited aggressive behaviors requiring emergency room transfer. | SS=D |
| Resident #115 was not assisted to maintain dignity during dining due to improper seating. | SS=D |
| Facility failed to consider and act on resident council grievances and recommendations. | SS=E |
| Facility failed to provide a safe, clean, comfortable, and homelike environment; multiple maintenance and housekeeping issues noted including damaged bathroom fixtures and unsafe heating units. | SS=E |
| Resident #52's quarterly MDS assessment inaccurately coded vision status. | SS=D |
| Care plan for Resident #42 failed to include interventions and side effects related to antiplatelet medication. | SS=D |
| Care plans for Residents #44 and #52 were not updated to reflect current behaviors and vision needs. | SS=D |
| Facility failed to follow physician orders for Resident #80; fasting blood sugar lab not obtained as ordered. | SS=D |
| Facility failed to provide or arrange psychiatric services timely for Resident #44 with mental and psychosocial difficulties. | SS=E |
| Facility failed to ensure residents' environment was free from accident hazards; electric baseboard heaters were damaged and posed risk. | SS=E |
| Facility failed to ensure food safety; employee failed to wash hands after nose wiping, ice machine drains improperly installed, and refrigerator in nutrition room was dirty and in disrepair. | SS=F |
| Facility failed to properly store and label medications and controlled substances; narcotic count sheets had missing signatures. | SS=E |
| Facility failed to maintain infection control; mechanical lifts not sanitized before and after use, uncovered toilet plunger in resident bathroom, and feces on washcloth left in resident room. | SS=F |
| Facility failed to maintain complete and accurate medical records; missing lab results, incomplete inventory of personal effects, and incomplete immunization consents and education documentation. | SS=F |
Report Facts
Residents present: 115
Survey dates: 11
Stage 2 residents sampled: 29
Surety bond amount: 76000
Residents with personal funds: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Named in grievance follow-up and surety bond discussion | |
| Licensed Practical Nurse (LPN) #61 | Named in verbal abuse incident with Resident #44 | |
| Licensed Practical Nurse (LPN) #142 | Reported verbal abuse incident and involved in Resident #44 care | |
| Registered Nurse (RN) #110 | Reviewed verbal abuse policy and Resident #44 care plan | |
| Activity Director #140 | Interviewed about resident council grievances and concierge program | |
| Referral Manager/Social Worker (RM/SW) | Handled grievance for Resident #52 | |
| Assistant Director of Nursing (ADON) | Involved in grievance follow-up and medication record review | |
| Maintenance Director | Interviewed about facility repairs and environmental concerns | |
| Licensed Practical Nurse (LPN) #104 | Observed medication storage and ice machine drain issues | |
| Cook #93 | Observed failing hand hygiene during food temperature checks | |
| Infection Control Nurse #102 | Interviewed about cleaning supplies and infection control practices | |
| Registered Nurse (RN)/Nurse Educator #110 | Reviewed lab results and medication orders | |
| Licensed Social Worker (LSW) #139 | Interviewed about Resident #44 psychiatric history | |
| Regional Nurse Consultant #147 | Reviewed controlled substance policies and medication storage |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 4
Jun 27, 2017
Visit Reason
The inspection was conducted as an annual survey of Fairmont Rehabilitation and Healthcare Center LLC to assess compliance with regulatory requirements including fire safety, smoking regulations, building system risk assessment, and electrical system maintenance.
Findings
The facility was found deficient in hazardous storage in bathrooms used as storage rooms, lack of a metal container with a self-closing lid in the smoking area, absence of a formal building system risk assessment, and incomplete documentation of generator battery electrolyte testing. Plans of correction were submitted for each deficiency.
Severity Breakdown
SS=C: 3
SS=B: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Hazardous storage in bathrooms on 200 and 300 halls containing combustibles with doors that do not resist smoke passage. | SS=C |
| Smoking area lacked a metal container with a self-closing lid for ashtray disposal. | SS=B |
| No documented formal risk assessment of building systems as required by NFPA 99. | SS=C |
| Failure to properly document weekly testing of all generator battery cells; only one cell tested per week. | SS=C |
Report Facts
Facility census: 117
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed observations and involved in corrective actions for hazardous storage, smoking area container, risk assessment, and generator battery testing | |
| NHA | Contacted Company Risk Management to ensure completion of building system risk assessment |
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Sep 29, 2016
Visit Reason
An unannounced revisit was conducted at Fairmont Health and Rehabilitation Center on September 29, 2016, to follow up on a previous complaint survey concluded on July 22, 2016.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.
Complaint Details
This was a revisit survey related to Complaint Survey #16032. The previously cited deficiencies were corrected.
Report Facts
Revisit survey sample: 9
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 3
Jul 18, 2016
Visit Reason
An unannounced complaint survey was conducted at Fairmont Health and Rehabilitation Center from July 18, 2016 to July 28, 2016, triggered by Complaint #16032 which was unsubstantiated but unrelated deficiencies were cited.
Findings
The facility failed to thoroughly investigate and report incidents of possible abuse and neglect involving five residents with seven separate incidents. Additionally, the facility failed to provide adequate treatment and prevention for pressure ulcers for one resident, and failed to maintain an effective infection control program due to ventilation issues between laundry and kitchen areas.
Complaint Details
Complaint #16032 was unsubstantiated with unrelated deficiencies cited. The complaint investigation included review of clinical records, resident, family and staff interviews, and facility documentation. The facility census on the first day of the complaint investigation was 113 residents.
Severity Breakdown
SS=E: 1
SS=G: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report incidents of possible abuse and/or neglect by staff for five residents with seven separate incidents. | SS=E |
| Failed to ensure residents admitted with existing pressure ulcers received necessary treatment to promote healing and prevent new sores, causing harm to one resident. | SS=G |
| Failed to maintain an effective infection control program by using fans in the laundry area that circulated air into the kitchen area. | SS=F |
Report Facts
Residents reviewed in complaint sample: 24
Facility census: 113
Number of abuse/neglect incidents: 7
Residents affected by abuse/neglect incidents: 5
Residents reviewed for pressure ulcers: 17
Resident #115 pressure ulcer measurements: Multiple measurements detailed in report text
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee Z | Confidential interview stating facility will not utilize wound clinic or wound vac, contributing to pressure ulcer development | |
| Nurse Aide #35 | Nurse Aide | Interviewed about repositioning Resident #115 |
| Assistant Director of Nursing | ADON | Interviewed regarding wound care and pressure ulcer management |
| Director of Nursing | DON | Interviewed regarding reporting of abuse/neglect incidents and wound care |
| Rehabilitation Director #15 | Rehabilitation Director | Interviewed regarding therapy and equipment for Resident #115 |
| Employee W | Confidential interview about wound care and discontinuation of wound vac | |
| Laundry Aide #97 | Laundry Aide | Interviewed about fan use in laundry room |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about air conditioning and ventilation issues |
Inspection Report
Plan of Correction
Deficiencies: 1
May 31, 2016
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey concluding on 04/25/2016, accepted in lieu of an onsite revisit.
Findings
The facility, Fairmont Rehabilitation and Healthcare Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information and legal rights. | Level C |
Report Facts
Survey completion date: May 31, 2016
Survey conclusion date: Apr 25, 2016
Inspection Report
Census: 117
Deficiencies: 2
Apr 20, 2016
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding smoke barrier fire resistance and emergency generator maintenance.
Findings
The facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating and failed to maintain the emergency generator in accordance with NFPA 110, including weekly testing and recording of the generator battery electrolyte fluid.
Severity Breakdown
SS=C: 1
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating. | SS=C |
| Facility failed to maintain the emergency generator in accordance with NFPA 110, including failure to test and record the specific gravity of electrolyte fluid in the generator battery weekly. | SS=B |
Report Facts
Facility census: 117
Deficiency completion date: Apr 27, 2016
Generator battery electrolyte tests: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to corrective actions for smoke barrier and generator battery deficiencies | |
| Maintenance Assistant | Named in relation to corrective actions for smoke barrier deficiency | |
| Maintenance Manager | Interviewed regarding smoke barrier and generator battery deficiencies |
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 4
Feb 18, 2016
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Fairmont Health and Rehabilitation Center from February 18, 2016 through February 25, 2016.
Findings
The survey identified multiple deficiencies including inaccurate dental assessments for residents, unsecured germicidal wipes posing accident hazards, improper food handling by staff, and failure to consistently monitor medication refrigerator temperatures.
Severity Breakdown
SS=D: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct a comprehensive, accurate, standardized assessment of residents' dental status for two residents (#2 and #91). | SS=D |
| Facility failed to provide an environment free from accident hazards; unsecured germicidal wipes found on nurses' station counter. | SS=E |
| Facility failed to distribute food under sanitary conditions; nurse aide buttered bread with bare hands. | SS=E |
| Failed to ensure staff consistently checked and recorded medication refrigerator temperatures in both medication rooms. | SS=E |
Report Facts
Facility census: 118
Survey sample size: 17
Omissions in refrigerator temperature recordings: 14
Omissions in refrigerator temperature recordings: 16
Omissions in refrigerator temperature recordings: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #118 | Registered Nurse | Stated Resident #2 had plaque in her mouth and commented on unsecured wipes |
| Minimum Data Set/Registered Nurse #115 | MDS Registered Nurse | Acknowledged incorrect dental assessment for Resident #2 and corrected it; assessed Resident #91's dental status |
| Nurse Aide #38 | Nurse Aide | Observed buttering bread with bare hands during lunch service |
| Director of Nursing | Director of Nursing | Stated staff must never touch residents' food with bare hands |
| Regional Nurse Consultant | Regional Nurse Consultant | Reported no specific food handling policy but advised staff to avoid touching food with bare hands |
| Registered Nurse #109 | Registered Nurse | Observed omissions in refrigerator temperature logs and commented on monitoring requirements |
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Jul 1, 2015
Visit Reason
An unannounced revisit was conducted at Arbors at Fairmont Campus from June 29, 2015 to July 1, 2015 for the Quality Indicator and Licensure Surveys concluding on May 14, 2015.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B. The revisit survey sample consisted of 25 residents.
Report Facts
Revisit survey sample size: 25
Inspection Report
Annual Inspection
Census: 111
Deficiencies: 21
May 14, 2015
Visit Reason
Unannounced annual Quality Indicator (extended) and State Licensure Surveys conducted from April 20, 2015 through May 14, 2015.
Findings
The facility was cited for multiple deficiencies including failure to notify physicians of critical blood pressure readings, failure to maintain resident privacy, failure to notify residents of roommate changes, incomplete criminal background checks for employees, failure to investigate and report alleged abuse, inaccurate resident assessments, incomplete care plans, medication errors, improper food handling, and ineffective quality assurance processes.
Severity Breakdown
SS=C: 1
SS=D: 10
SS=E: 4
SS=F: 5
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to notify physicians when residents' blood pressures were outside established parameters for notification. | SS=C |
| Failure to maintain resident privacy during personal care. | SS=D |
| Failure to notify residents of roommate changes prior to the change. | SS=D |
| Failure to complete timely criminal background checks and nurse aide registry checks for employees. | SS=F |
| Failure to investigate and report resident-to-resident abuse and failure to implement measures to prevent further abuse. | SS=F |
| Inaccurate quarterly minimum data set (MDS) assessment related to resident dental status. | SS=D |
| Failure to revise care plans to reflect changes in resident condition and physician orders. | SS=D |
| Failure to provide activities as outlined in care plan for a resident with dementia. | SS=D |
| Failure to provide care and services by qualified persons in accordance with the plan of care. | SS=D |
| Failure to ensure resident environment was free of accident hazards and failure to provide assistive devices as ordered. | SS=D |
| Failure to maintain acceptable nutritional status and failure to address refusal of nutritional supplements. | SS=D |
| Medication errors including crushing extended-release tablets, administering medications without current physician orders, and incorrect medication timing. | SS=E |
| Failure to date opened multi-dose insulin vials and failure to discard them within recommended timeframes. | SS=E |
| Failure to ensure pharmacist monthly drug regimen reviews were acted upon timely by physicians. | SS=D |
| Failure to maintain sanitary conditions in food preparation and storage areas, including contaminated equipment and improper food storage. | SS=D |
| Failure to properly dispose of garbage and refuse, resulting in overflowing dumpsters and trash on the ground. | SS=D |
| Failure to maintain an infection control program to prevent spread of infection, including improper linen handling and storage of soiled items. | SS=F |
| Failure to complete annual nurse aide performance reviews for some employees. | SS=F |
| Failure to obtain laboratory tests as ordered and failure to notify physicians of lab results. | SS=D |
| Failure to maintain accurate medical records, including documentation of sunscreen application. | SS=E |
| Failure to maintain a functioning Quality Assessment and Assurance Committee that identifies and corrects quality deficiencies. | SS=F |
Report Facts
Facility census: 111
Medication error rate: 11.11
Weight loss: 13.4
Number of documented falls: 6
Number of blood pressure readings outside parameters: 47
Number of blood pressure readings outside parameters: 38
Number of nurse aides without annual competency review: 3
Number of employees without timely criminal background checks: 4
Number of employees without nurse aide registry check: 1
Number of opportunities for sunscreen application: 52
Number of sunscreen refusals: 47
Number of medication administration opportunities: 54
Number of medication errors: 6
Number of bags of trash on ground: 9
Number of documented incidents of bruising: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN #60 did not notify physician of critical blood pressures for Resident #32 | |
| Registered Nurse | RN #43 confirmed physician was not notified of critical blood pressures for Resident #32 | |
| Licensed Practical Nurse | LPN #59 crushed extended-release tablets for Resident #85 | |
| Assistant Director of Nursing | ADON acknowledged no signed physician order for Glipizide for Resident #85 | |
| Registered Nurse | RN #32 acknowledged omission of Flomax medication for Resident #78 | |
| Director of Nursing | DON acknowledged missed lab tests for Resident #84 | |
| Consultant Pharmacist | Pharmacist failed to identify lack of physician notification for blood pressure abnormalities | |
| Nurse Aide | NA #74 improperly carried linens against chest | |
| Registered Nurse | RN #46 acknowledged insulin vials not dated when opened | |
| Licensed Practical Nurse | LPN #76 administered Clonidine at incorrect times for Resident #164 | |
| Licensed Practical Nurse | LPN #76 omitted Flomax medication for Resident #78 | |
| Licensed Practical Nurse | LPN #59 crushed Protonix delayed-release tablet for Resident #85 | |
| Licensed Practical Nurse | LPN #59 administered Glipizide without current physician order for Resident #85 | |
| Licensed Practical Nurse | LPN #59 crushed Mucinex extended-release tablets for Resident #85 | |
| Nurse Aide | NA #39, #100, #119 lacked annual competency evaluations |
Inspection Report
Annual Inspection
Census: 111
Capacity: 120
Deficiencies: 4
Apr 22, 2015
Visit Reason
The inspection was conducted as an annual survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements at Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The facility was found deficient in maintaining smoke barrier walls with required fire resistance, ensuring exit access was readily accessible, maintaining sprinkler systems free from external loads and debris, and enforcing smoking regulations including employee smoking areas and provision of ashtrays and metal containers.
Severity Breakdown
SS=A: 1
SS=B: 2
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain smoke barrier walls to provide at least one half hour fire resistance rating as required by NFPA 101 Life Safety Code. | SS=B |
| Failed to ensure exit access is readily accessible at all times; exit discharge paths led to parking spaces with no direct path to public way. | SS=B |
| Failed to maintain sprinkler pipes free from external loads, maintain sprinkler heads free of foreign material, and maintain sprinkler escutcheons to limit heat transfer. | SS=C |
| Smoking regulations did not include information about employee smoking or designate areas where smoking is allowed, nor did they ensure ashtrays and metal containers are provided and available in all smoking areas. | SS=A |
Report Facts
Facility census: 111
Total capacity: 120
Inspection date: Apr 22, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during inspection and acknowledged deficiencies related to smoke barrier, exit access, sprinkler system, and smoking area | |
| Maintenance staff | Present during inspection and acknowledged deficiencies related to smoke barrier and sprinkler system |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 31, 2014
Visit Reason
The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation concluding on 2014-12-10.
Findings
The facility, Arbors at Fairmont, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with the previously cited deficient practice corrected.
Complaint Details
Complaint Reference: 12122. The complaint investigation concluded with the facility in substantial compliance and no onsite revisit was required.
Report Facts
Complaint Reference Number: 12122
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Dec 10, 2014
Visit Reason
An unannounced complaint survey was conducted from December 1 to December 10, 2014, based on complaint #12122 which was substantiated with a related deficiency cited.
Findings
The facility failed to establish and maintain an effective Infection Control Program, specifically neglecting to implement contact precautions immediately after admitting two residents with confirmed Clostridium difficile infections. This failure had the potential to affect multiple residents. The investigation included staff, family, and resident interviews, record reviews, and policy assessments.
Complaint Details
Complaint #12122 was substantiated. The complaint involved failure to implement infection control precautions for residents with C. diff infections, specifically residents #113 and #111.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement contact precautions immediately after admitting residents with confirmed Clostridium difficile infections. | SS=E |
Report Facts
Complaint sample size: 13
Facility census: 111
Dates of complaint survey: December 1, 2014 to December 10, 2014
Vancomycin treatment duration for Resident #113: 6
Vancomycin treatment duration for Resident #111: 7
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Apr 29, 2014
Visit Reason
An unannounced complaint investigation was conducted from 04/29/14 to 04/30/14 at Arbors at Fairmont in response to a complaint reference.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was found to be in substantial compliance with applicable federal and state nursing home regulations.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Report Facts
Sample size: 10
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 15, 2014
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Report Facts
Provider/Supplier Identification Number: 515189
Inspection Report
Annual Inspection
Census: 115
Deficiencies: 9
Dec 11, 2013
Visit Reason
The inspection was conducted as part of a Quality Indicator and State Licensure Survey from 12/02/13 to 12/11/13.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, failure to implement policies on neglect and misappropriation of resident property, dignity and respect in care, care plan revisions, medication administration timeliness, infection control, and compliance with state hospice palliative care notification requirements.
Severity Breakdown
SS=E: 1
SS=D: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure effective housekeeping and maintenance services; observed food-like substances on a resident's wheelchair and mold-like substances in shower areas. | SS=E |
| Facility failed to implement policies regarding neglect and misappropriation of resident property; clothing purchased without resident's permission and dehydration allegation not reported. | SS=D |
| Facility failed to report allegations of neglect and misappropriation timely and investigate properly. | SS=D |
| Facility failed to provide care maintaining resident dignity; nurse aide stood over resident while feeding. | SS=D |
| Facility failed to revise care plans timely after changes in orders for two residents. | SS=D |
| Facility failed to provide services per care plan; missing non-skid material in wheelchair. | SS=D |
| Facility failed to dispense medications timely; digoxin dose administered 1.5 hours late. | SS=D |
| Facility failed to maintain infection control during dressing changes and failed to keep wheelchair clean. | SS=D |
| Facility failed to comply with state hospice palliative care notification requirements for a resident on comfort measures. | SS=D |
Report Facts
Facility census: 115
Deficiency count: 9
Medication delay: 1.5
Resident count: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #34 | Registered Nurse | Reported food-like substances on Resident #109's wheelchair and agreed to clean it |
| Employee #25 | Infection Control Nurse | Agreed wheelchair seat contained food-like substances |
| Employee #5 | Licensed Social Worker | Involved in clothing purchase issue for Resident #33 and complaint reporting |
| Employee #13 | Licensed Social Worker | Attempted to speak to Resident #33 and completed concern report |
| Employee #7 | Maintenance Supervisor | Acknowledged cracked tiles and mold in shower areas |
| Employee #113 | Housekeeping Supervisor | Reported cleaning schedule and unsuccessful mold removal attempts |
| Employee #63 | Nurse Aide | Observed standing over Resident #88 while feeding |
| Employee #44 | Licensed Practical Nurse | Administered digoxin late to Resident #10 and reported medication storage issue |
| Employee #22 | Licensed Practical Nurse | Observed breaching infection control during dressing change for Resident #59 |
| Employee #2 | Director of Nursing | Reported medication storage issue and discussed infection control breaches |
Inspection Report
Life Safety
Deficiencies: 0
Dec 3, 2013
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2013
Visit Reason
The inspection was conducted in response to a complaint referenced as 8657 / 13196.
Findings
The complaint was found to be unsubstantiated with no citations issued.
Complaint Details
Complaint Reference: 8657 / 13196. The complaint was unsubstantiated with no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2013
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint number 8169 - 13120.
Findings
The complaint was found to be unsubstantiated and no citations were issued.
Complaint Details
Complaint Reference: 8169 - 13120. The complaint was unsubstantiated with no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 5, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on two complaint references: 13068 / 7872 and 13074 / 7903.
Findings
Both complaint investigations were unsubstantiated with no citations issued.
Complaint Details
Complaint Reference: 13068 / 7872 - Unsubstantiated complaint record with no citations. Complaint Reference: 13074 / 7903 - Unsubstantiated complaint record with no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2013
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint number 12244 / 7394.
Findings
The complaint was found to be unsubstantiated and no citations were issued during the investigation.
Complaint Details
Complaint Reference: 12244 / 7394. The complaint was unsubstantiated with no citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 19, 2012
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights, rules, services, and charges as required. | Level C |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 30, 2012
Visit Reason
Onsite revisit to recertification survey conducted from 08/27/12 to 08/30/12 to verify compliance with previously cited tags during the survey completed on 06/22/12.
Findings
Based on medical record review, staff interviews, resident interviews, resident council meeting, kitchen observations, dining observations, and facility observations, the facility was determined to be in compliance with all tags cited during the prior survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 24, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on two complaint references: 12160 / 7213 and 12124 / 7146.
Findings
Both complaint investigations were unsubstantiated and resulted in no citations.
Complaint Details
Complaint Reference: 12160 / 7213 and 12124 / 7146 were both unsubstantiated with no citations issued.
Report Facts
Complaint References: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 23, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference 12170 / 7231.
Findings
The complaint was found to be unsubstantiated with no citations issued during the investigation.
Complaint Details
Complaint reference 12170 / 7231 was investigated and found to be unsubstantiated with no citations.
Report Facts
Complaint reference number: 12170
Inspection Report
Annual Inspection
Capacity: 120
Deficiencies: 15
Jun 22, 2012
Visit Reason
Recertification survey conducted from 06/18/12 to 06/22/12 to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including residents' rights, quality of life, activities, admission orders, comprehensive assessments, care planning, provision of services, medication management, infection control, nutrition, and quality assurance. Specific issues included failure to promote voting rights, inadequate mental health and activity programs, medication errors, incomplete assessments, lack of resident participation in care planning, failure to follow physician orders, unsafe environment hazards such as elevated water temperatures, and poor food quality and temperature control.
Severity Breakdown
SS=F: 5
SS=E: 6
SS=D: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure residents were provided the opportunity to exercise their rights as citizens, including voting assistance. | SS=E |
| Failure to provide an environment that enhanced quality of life for residents with mental health needs and pressure ulcers. | SS=D |
| Failure to provide individualized activities meeting residents' interests and needs. | SS=D |
| Failure to ensure admission physician orders were carried out timely and accurately. | SS=D |
| Failure to conduct comprehensive and accurate resident assessments. | SS=D |
| Failure to ensure residents participated in care planning and care plans were revised as needed. | SS=E |
| Failure to provide services in accordance with the written care plan, including medication administration, use of assistive devices, and oxygen therapy. | SS=E |
| Failure to maintain nutritional status, including failure to monitor weight changes, provide appropriate diet portions, and assess causes of weight loss. | SS=E |
| Failure to ensure drug regimens were free from unnecessary drugs, including failure to monitor and reassess medications such as Megace and Lovenox. | SS=E |
| Failure to remove expired medications from medication carts, resulting in administration of expired insulin to residents. | SS=D |
| Failure to maintain an effective infection control program, including failure to assess wounds for isolation, track all infections, and ensure hand hygiene. | SS=F |
| Failure to provide food that was palatable, attractive, and served at proper temperatures, including serving cold food and lack of variety. | SS=F |
| Failure of the medical director to provide oversight and collaboration in quality assurance and drug regimen reviews. | SS=F |
| Failure to obtain timely laboratory services for residents. | SS=D |
| Failure to maintain accurate and complete clinical records, including timely physician signatures, documentation of falls and notifications, and maintenance of required assessments. | SS=F |
Report Facts
Resident capacity: 120
Weight loss: 13.7
Weight loss: 12.7
Water temperature: 120
Urinary tract infections: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN23 | Registered Nurse | Interviewed regarding care plan participation, care plan accuracy, and oxygen therapy |
| RN28 | Registered Nurse, Infection Control Nurse | Interviewed regarding infection control program and infection tracking |
| LPN20 | Licensed Practical Nurse | Interviewed regarding pressure sore risk assessment and care plan accuracy |
| LPN24 | Licensed Practical Nurse | Interviewed regarding expired insulin administration |
| LPN25 | Licensed Practical Nurse | Interviewed regarding resident transfers and medication administration |
| CNA71 | Certified Nursing Assistant | Interviewed regarding use of Geri gloves and Geri legs, and bed alarm |
| CNA72 | Certified Nursing Assistant | Observed not sanitizing hands between resident contacts |
| CNA68 | Certified Nursing Assistant | Observed not sanitizing hands between resident contacts |
| CDM | Certified Dietary Manager | Interviewed regarding food preparation and menu items |
| DON | Director of Nursing | Interviewed regarding quality assurance and medication regimen review |
| MD | Medical Director | Interviewed regarding medication regimen review and quality assurance |
Inspection Report
Life Safety
Census: 113
Capacity: 120
Deficiencies: 3
Jun 21, 2012
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the construction and maintenance of smoke barrier walls in the facility.
Findings
The facility failed to maintain smoke barrier walls to provide at least a one half hour fire resistance rating. Multiple penetrations in the smoke barrier wall in the attic were found not completely sealed, compromising the fire resistance.
Deficiencies (3)
| Description |
|---|
| Two grey wires penetrating the smoke barrier wall are not completely sealed. |
| Another group of wires penetrating the smoke barrier wall is not completely sealed. |
| A metal pipe containing a bundle of wires is not completely sealed around the pipe where it meets the drywall. |
Report Facts
Facility census: 113
Total capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Terry Wilson | Maintenance Staff | Acknowledged the unsealed penetrations in the smoke barrier wall during inspection |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Aug 12, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to substantiated complaints about resident safety and supervision, specifically concerning aggressive behaviors by Resident #119.
Findings
The facility failed to ensure a safe environment free from accident hazards by not adequately supervising Resident #119, who exhibited aggressive behaviors resulting in physical abuse of six residents and injury to one resident. The facility did not implement appropriate interventions or increased supervision to prevent these incidents.
Complaint Details
Complaint reference #10222 was substantiated with deficiencies cited. Complaint reference #10217 was unsubstantiated with no related deficiencies cited.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remained free of accident hazards and to provide adequate supervision to prevent accidents related to aggressive behaviors of Resident #119. | SS=G |
Report Facts
Resident stay duration: 77
Number of resident-to-resident physical altercations: 6
Facility census: 117
Incident dates: 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) - Employee #26 | Designated in charge during investigation; confirmed lack of adequate supervision and interventions for Resident #119 | |
| Facility Social Worker - Employee #5 | Confirmed social service progress notes regarding no attempts to transfer Resident #119 prior to transfer on 08/09/10 |
Inspection Report
Life Safety
Deficiencies: 0
Mar 16, 2010
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Routine
Census: 112
Deficiencies: 12
Mar 4, 2010
Visit Reason
Routine inspection of Fairmont Rehabilitation and Healthcare Center LLC to assess compliance with regulatory requirements including resident rights, security of personal funds, notice requirements, employee screening, activities program, care planning, medication administration, infection control, and laboratory services.
Findings
The facility was found deficient in multiple areas including failure to post correct state agency contact information, lack of current surety bond for resident funds, incorrect transfer/discharge notices, inadequate employee screening for abuse and neglect, failure to provide group outings, failure to develop and implement care plans for fluid and electrolyte balance, medication administration errors, failure to obtain timely laboratory tests, incomplete tuberculosis screening, inadequate hand hygiene policy, and incomplete maintenance of laboratory reports in resident records.
Severity Breakdown
SS=E: 6
SS=D: 4
SS=F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to post correct names, addresses, and telephone numbers of all pertinent State agencies. | SS=E |
| Failed to obtain a current surety bond to protect all personal funds of residents deposited with the facility. | SS=E |
| Failed to provide correct contact information on transfer/discharge notices for State long-term care ombudsman and protection and advocacy agencies. | SS=E |
| Failed to screen employees for convictions of abuse, neglect, or mistreatment prior to resident contact. | SS=E |
| Failed to provide an ongoing program of activities designed to meet interests and psychosocial well-being of residents, including group outings. | SS=E |
| Failed to develop and implement a care plan to address fluid and electrolyte balance for a resident with chronic kidney disease and history of dehydration, resulting in actual harm. | SS=D |
| Failed to ensure medications were administered according to physician orders for two residents. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs; Risperdal given without adequate indication. | SS=D |
| Failed to establish handwashing guidelines in accordance with CDC standards. | SS=F |
| Failed to provide or obtain laboratory services timely as ordered by physician for multiple residents. | SS=E |
| Failed to maintain laboratory reports in resident medical records. | SS=D |
| Failed to follow facility policy on tuberculosis screening; second step PPD not completed or documented. | SS=F |
Report Facts
Facility census: 112
Deficiencies cited: 12
Potassium level: 6.1
Lasix dosage: 40
Potassium Chloride dosage: 30
Metoprolol dosage: 150
Metoprolol dosage given: 100
Risperdal dosage: 0.5
CBC test frequency: 1
Thyroid test frequency: 6
PTT test frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Business Office Director | Interviewed regarding surety bond |
| Employee #6 | Assistant Activity Director | Interviewed about group outings |
| Employee #10 | Activity Director | Interviewed about group outings |
| Employee #12 | Medical Records Staff | Reviewed Resident #108 lab results |
| Employee #21 | Nurse | Called physician regarding lab orders for Resident #108 |
| Employee #25 | Nurse | Medication pass and interview regarding medication errors and lab tests |
| Employee #38 | Nurse | Interviewed about lab test tickler system |
| Employee #97 | Contracted Nursing Employee | Lack of background check and nurse aide registry screening |
| Employee #103 | Contracted Nursing Employee | Lack of background check |
| Employee #108 | Contracted Nursing Employee | Lack of background check and nurse aide registry screening |
| Employee #111 | Contracted Nursing Employee | Lack of background check and nurse aide registry screening |
| Employee #113 | Contracted Nursing Employee | Lack of background check and nurse aide registry screening |
| Employee #2 | Director of Nursing | Acknowledged missing lab tests and inadequate medication indications |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 2
Jul 27, 2009
Visit Reason
The inspection was conducted in response to complaint reference #9205, which was found to be unsubstantiated, with unrelated deficiencies cited.
Findings
The facility failed to accurately post the actual resident census and numbers of licensed practical nurses and nursing assistants on the day shift of 07/26/09. Additionally, the facility failed to change oxygen tubing weekly for residents prescribed oxygen therapy, contrary to facility policy and physician orders.
Complaint Details
Complaint reference #9205 was unsubstantiated, but unrelated deficiencies were cited during the investigation.
Severity Breakdown
Level C: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to accurately post actual resident census and numbers of licensed practical nurses and nursing assistants on the day shift. | Level C |
| Failed to change oxygen tubing weekly for residents prescribed oxygen therapy, as required by physician orders and facility policy. | Level E |
Report Facts
Resident census: 112
Nursing assistants reported on staffing form: 15.9
Nursing assistants observed: 13
Licensed practical nurses reported on staffing form: 4.9
Licensed practical nurses observed: 4
Residents with oxygen tubing not changed weekly: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor | Confirmed inaccuracies in nurse staffing posting form on 07/26/09 | |
| Director of Nurses | Provided facility policy on oxygen tubing change schedule on 07/27/09 |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 23, 2009
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance at Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 120
Deficiencies: 1
May 14, 2009
Visit Reason
The inspection was conducted as a complaint investigation referencing complaints #9050 and #9106, which were substantiated with deficiencies cited.
Findings
The facility failed to deploy sufficient direct care nursing staff across all shifts and units to meet the assessed care needs of dependent residents, affecting more than an isolated number of residents. Staffing shortages were documented on multiple shifts and dates, impacting resident care tasks such as rounds, repositioning, incontinence care, and snack distribution.
Complaint Details
Complaint references #9050 and #9106 were substantiated with deficiencies cited.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to deploy sufficient nursing staff to meet resident care needs as per care plans. | SS=E |
Report Facts
Facility census: 119
Total licensed beds: 120
Nursing staff on 3-11 shift on 05/10/09: 10
Nursing staff on 11-7 shift on 05/10-05/11/09: 8
Nursing staff on 11-7 shift on 05/13/09: 7
Nursing hours for 11-7 shift: 60
Residents incontinent of bladder: 70
Residents incontinent of bowel: 70
Residents in chair all or most of the time: 56
Residents with psychiatric diagnoses: 41
Residents with dementia: 69
Residents with behavioral symptoms: 41
Residents developing pressure ulcers since admission: 5
Residents receiving preventive skin care: 118
Inspection Report
Life Safety
Deficiencies: 0
Jan 15, 2009
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 11
Jan 8, 2009
Visit Reason
The inspection was conducted as a complaint investigation concurrently with the facility's annual Federal Medicare / Medicaid certification resurvey and State licensure inspection.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during showers, improper use and documentation of physical restraints and enablers, failure to report and investigate allegations of abuse and injuries, inaccurate and incomplete resident assessments and care plans, failure to provide care according to plans, improper infection control practices, failure to maintain assistive devices, and failure to maintain a quality assessment and assurance committee that monitors infection control.
Complaint Details
Complaint reference #2-8348 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual certification resurvey and licensure inspection.
Severity Breakdown
SS=E: 5
SS=D: 4
SS=B: 1
SS=F: 1
: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to maintain resident privacy during showers for multiple residents due to improper use of shower curtains and partitions. | SS=E |
| Facility failed to assure physical restraints were ordered by a physician and properly documented; inconsistent use of lap buddies as restraints or enablers; resident injuries related to restraint use. | SS=E |
| Facility failed to immediately report and thoroughly investigate injuries of unknown origin and allegations of abuse to appropriate State agencies. | SS=D |
| Facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for multiple residents. | SS=B |
| Facility failed to develop individualized comprehensive care plans reflecting actual care and services provided for multiple residents. | SS=E |
| Facility failed to provide care in accordance with each resident's plan of care, including pain management, fluid intake monitoring, contracture prevention, and ordered treatments. | SS=D |
| Facility failed to assist residents with use of assistive devices needed to maintain hearing or vision. | SS=D |
| Facility failed to ensure oxygen delivery supplies were changed weekly as per policy for multiple residents. | — |
| Facility failed to ensure medication regimen was free from unnecessary drugs; psychoactive medications were added without adequate assessment or psychiatric consultation. | SS=D |
| Facility failed to serve food under sanitary conditions; cups and bowls were air dried inverted on flat trays with trapped moisture. | SS=F |
| Facility failed to maintain an effective infection control program; infectious organisms were not tracked or analyzed for trends; infection control data was incomplete and not reviewed by QAA committee. | SS=E |
Report Facts
Facility census: 113
Number of residents with infections in October 2008: 22
Number of residents with infections in November 2008: 24
Number of residents with infections in December 2008: 18
Number of pages in Resident #36 care plan: 64
Number of pages related to falls in Resident #36 care plan: 27
Number of pages related to safety devices in Resident #36 care plan: 20
Number of days oxygen tubing was dated before inspection: 18
Number of days nebulizer tubing was dated before inspection: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Director of Nursing (DON) | Named in multiple findings including restraint use, complaint investigation, infection control, and care plan deficiencies |
| Employee #23 | Minimum Data Set (MDS) Nurse | Named in findings related to inaccurate MDS assessments and care plan documentation |
| Employee #27 | Nurse | Named in observations of ice pass and infection control |
| Employee #45 | Assistant Dietary Manager | Named in findings related to improper drying of cups and bowls |
| Employee #42 | Dietary Manager | Named in findings related to improper drying of cups and bowls |
| Employee #58 | Nursing Assistant | Named in observations of ice pass with potential contamination |
| Employee #63 | Nursing Assistant | Named in findings related to toileting plans and hearing aid assistance |
| Employee #100 | Corporate Nurse | Named in observations of ice pass and infection control |
| Employee #1 | Administrator | Named in infection control and ice pass findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 30, 2008
Visit Reason
The inspection was conducted in response to complaint reference #2-8235.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8235 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 22, 2008
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified during a prior inspection.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, with acknowledgment of receipt.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | SS=C |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Sep 5, 2008
Visit Reason
The inspection was conducted in response to complaint reference #2-8211, which was found to be unsubstantiated, with unrelated deficiencies cited.
Findings
The facility failed to ensure that a resident who was unable to self-administer medications was observed by nursing staff during a respiratory treatment. Resident #61 was left alone during the treatment, and the respiratory device came undone, preventing the resident from receiving the full benefit of the treatment.
Complaint Details
Complaint reference #2-8211 was unsubstantiated with unrelated deficiencies cited.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident who was unable to self-administer medications was observed by nursing staff during a respiratory treatment, resulting in incomplete treatment. | Level D |
Report Facts
Facility census: 120
Respiratory treatments ordered: 4
Oxygen concentration: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 observed the respiratory device was undone and called for the nurse caring for Resident #61 | ||
| Facility Administrator | Participated in exit conference and stated expectation that staff stay with resident during respiratory treatment | |
| Director of Nursing | Participated in exit conference and stated expectation that staff stay with resident during respiratory treatment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 11, 2008
Visit Reason
The inspection was conducted in response to a complaint referenced as 2-8178.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
Complaint reference: 2-8178. Unsubstantiated complaint record with no deficiencies cited.
Report Facts
Complaint reference number: 28178
Inspection Report
Plan of Correction
Deficiencies: 1
May 22, 2008
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Report Facts
Event ID: 860Y11
Facility ID: WV51E127
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 11
Apr 2, 2008
Visit Reason
Complaint investigations were conducted concurrently with the facility's Federal Medicare/Medicaid certification survey and State licensure inspection. The visit included substantiated and unsubstantiated complaints.
Findings
The facility had multiple deficiencies including failure to assure residents' rights, improper use of physical restraints, inadequate accommodation of needs, incomplete comprehensive assessments, failure to conduct assessments after significant changes, inaccurate resident assessments, incomplete care plans, failure to provide necessary care and services, inadequate pressure sore prevention and treatment, unsanitary food handling practices, and expired medications in stock.
Complaint Details
Complaint reference #2-8057 unsubstantiated with no deficiencies cited; #2-8074 substantiated with deficiencies cited; #2-8100 unsubstantiated with no deficiencies cited.
Severity Breakdown
SS=C: 2
SS=D: 5
SS=E: 2
SS=F: 1
SS=G: 1
SS=H: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to assure the rights of one resident adjudged incompetent were exercised according to state law. | SS=D |
| Use of physical restraint (seat belt) without assessment of need and used for staff convenience. | SS=D |
| Failure to provide wheelchairs that allowed residents to eat comfortably at dining tables. | SS=E |
| Incomplete resident assessment protocols (RAPs) documentation for two residents. | SS=D |
| Failure to conduct comprehensive assessment after significant change for one resident with Stage IV pressure sore and weight loss. | SS=D |
| Inaccurate minimum data set (MDS) assessments for two residents; restraint not indicated and dental problems not identified. | SS=D |
| Failure to develop, review, and revise comprehensive care plans for residents with pressure sores, recurrent UTIs, and physical restraint use. | SS=E |
| Failure to provide necessary care and services to maintain highest practicable well-being for residents including choking response, infection assessment, timely medication administration, and proper positioning. | SS=G |
| Failure to ensure residents were assessed and treated for pressure sores, including failure to complete dressing changes and body audits as ordered. | SS=H |
| Failure to serve food under sanitary conditions including improper glove use and stacking of plastic tumblers causing contamination risk. | SS=F |
| Failure to dispose of expired medications; expired rectal suppositories found in refrigerated storage. | SS=C |
Report Facts
Facility census: 118
Residents sampled: 21
Pressure sore size: 3
Weight loss percentage: 12.5
Pressure sore size: 1.4
Pressure sore size: 2
Pressure sore size: 3.5
Pressure sore size: 5
Pressure sore size: 1.5
Pressure sore size: 0.5
Pressure sore size: 0.2
Pressure sore size: 1.3
Pressure sore size: 1
Pressure sore size: 4
Pressure sore size: 1.3
Pressure sore size: 2
Pressure sore size: 3.5
Pressure sore size: 2.2
Pressure sore size: 2
Pressure sore size: 5
Pressure sore size: 1.5
Expired medication date: 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed understanding of resident rights requirements and care plan updates | |
| Licensed Practical Nurse (Employee #21) | Discussed restraint use on resident #126 | |
| Dietitian | Observed residents seated too low in wheelchairs and responded to choking resident | |
| MDS Coordinator (Employee #24) | Acknowledged failure to complete significant change MDS | |
| Registered Nurse (Employee #40) | Discussed delayed IV antibiotic administration for resident #72 | |
| Nurse (Employee #27) | Confirmed missed medication dose for resident #112 | |
| Assistant Director of Nursing (ADON) | Confirmed failure to complete body audits and dressing changes | |
| Dietary Manager (Employee #43) | Confirmed food safety violations | |
| Nurse (Employee #33) | Confirmed expired medications in stock |
Inspection Report
Life Safety
Deficiencies: 0
Mar 20, 2008
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2008
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-8020.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8020 was unsubstantiated with no deficiencies cited.
Inspection Report
Monitoring
Deficiencies: 0
Aug 30, 2007
Visit Reason
A Comparative Federal Monitoring Survey was conducted following a State Survey Agency Survey to assess compliance with federal regulations for long term care facilities.
Findings
At this Comparative Federal Monitoring Survey, Arbors at Fairmont was found in compliance with the Requirements for Participation for Medicare and Medicaid, specifically with Life Safety from Fire regulations.
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 23, 2007
Visit Reason
The document is a plan of correction related to a paper revisit of a prior inspection at Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The document references a deficiency related to informing residents of their rights and facility rules, specifically under regulation 483.10(b)(5)-(10), but does not provide detailed findings beyond this.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2007
Visit Reason
The inspection was conducted in response to complaint reference #2-7176.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-7176 was unsubstantiated with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Jul 19, 2007
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review conducted.
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 7
Jul 5, 2007
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident care, medication management, infection control, and sanitary conditions.
Findings
The facility was found deficient in multiple areas including failure to develop and update comprehensive care plans for residents with acute changes, failure to ensure pre-admission screening forms were approved prior to admission, inadequate monitoring of residents' conditions, unnecessary use of drugs including antipsychotics and muscle relaxants, unsanitary food service practices, failure of the pharmacist to identify medication irregularities, and inadequate infection control practices related to medication administration.
Severity Breakdown
SS=D: 6
SS=B: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop or update comprehensive care plans with appropriate goals and interventions for two residents. | SS=D |
| Failed to ensure pre-admission screening forms were reviewed and approved prior to admission for three residents. | SS=B |
| Failed to monitor care and services for a resident with an acute change in condition. | SS=D |
| Unnecessary use of drugs including antipsychotic, antianxiety, and muscle relaxant medications in excessive doses and durations without adequate monitoring. | SS=D |
| Failed to ensure food was served under sanitary conditions; dietary staff placed a diet slip that fell on the floor back on a resident's tray. | SS=D |
| Failed to ensure the consultant pharmacist identified and reported irregularities in residents' medication regimens. | SS=D |
| Failed to ensure medication measuring devices were properly sanitized between uses to prevent spread of infection. | SS=D |
Report Facts
Facility census: 116
Residents sampled: 21
Residents with deficient pre-admission screening: 3
Residents with unnecessary drug use: 3
Dosage of Seroquel for Resident #72: 400
Dosage of Xanax for Resident #72: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Social Worker | Acknowledged delayed approval of PAS2000 pre-admission screening forms |
| Employee #10 | Dietitian | Explained Risperdal was restarted due to weight loss and loss of appetite |
| Employee #41 | Dietary Manager | Confirmed diet slip should not have been placed back on tray after falling on floor |
| Director of Nursing | Director of Nursing | Interviewed regarding fluid monitoring, medication irregularities, and infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2007
Visit Reason
The inspection was conducted in response to complaint references #2-7081 and #2-7082.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the inspection.
Complaint Details
Complaint references #2-7081 and #2-7082 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 22, 2007
Visit Reason
This document is a plan of correction submitted by Fairmont Rehabilitation and Healthcare Center LLC following a survey inspection.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Feb 28, 2007
Visit Reason
The inspection was conducted as a complaint investigation (reference #2-7024) which was substantiated with deficiencies cited.
Findings
The facility was found to have deficiencies related to unnecessary drug use, specifically an excessive dose of Thorazine given to Resident #121 resulting in sedation lasting more than 24 hours. The resident's medication regimen was not free from unnecessary drugs, and the resident's condition regressed following the medication administration.
Complaint Details
Complaint reference #2-7024 was substantiated with deficiencies cited related to unnecessary drug use.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #121 received an intramuscular injection of Thorazine in an excessive dose causing sedation lasting over 24 hours. | SS=D |
Report Facts
Facility census: 117
Medication dose: 100
Medication dose: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed staff who worked with Resident #121 and provided information about the medication administration and resident condition | |
| Administrator | Provided information about Resident #121's family support and discharge |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 27, 2007
Visit Reason
The visit was a paper revisit to follow up on previous deficiencies at the facility.
Findings
The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are noted but detailed findings are not fully provided in the excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | Level C |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Jan 12, 2007
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-6311, focusing on the facility's compliance with notification requirements prior to resident transfers or discharges.
Findings
The facility was found to have failed in providing timely and informative notification to residents or their legal representatives prior to discharge. Specifically, five of eight sampled resident records showed that discharge notices were mailed after the residents had already been discharged.
Complaint Details
Complaint reference #2-6311 was substantiated with deficiencies cited related to failure to notify residents or their legal representatives prior to discharge.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide residents or their legal representatives with timely and informative notification of transfer or discharge prior to the event. | SS=E |
Report Facts
Facility census: 118
Residents with late discharge notices: 5
Sampled resident records: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employees #1, #2, and #3 confirmed that discharge notices were sent after the discharges for the sampled residents. |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 1, 2006
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Fairmont Rehabilitation and Healthcare Center LLC.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Life Safety
Census: 113
Capacity: 120
Deficiencies: 4
May 16, 2006
Visit Reason
A Comparative Federal Monitoring Survey was conducted following a State Survey Agency Survey to assess compliance with life safety code requirements for a skilled nursing facility.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in the fire alarm system, smoke detector maintenance and testing, fire extinguisher provision, and emergency generator emergency task illumination.
Severity Breakdown
SS=F: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| The automatic dialer component of the fire alarm system did not send a trouble signal to the main fire alarm control panel, causing inconsistent trouble signal notifications. | SS=F |
| The facility failed to maintain and test smoke detectors; no current or complete sensitivity testing documentation was provided. | SS=F |
| The facility failed to provide a required Class K fire extinguisher in the kitchen area. | SS=E |
| The facility failed to provide emergency battery task illumination at the emergency generator set locations. | SS=F |
Report Facts
Licensed skilled nursing beds: 120
Census: 113
Residents affected by fire extinguisher deficiency: 36
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 6
Mar 23, 2006
Visit Reason
Complaint investigation related to resident rights, care, and facility practices, including documentation of incapacity, availability of linens, laboratory testing, supervision to prevent accidents, unnecessary drug use, and infection control.
Findings
The facility was found deficient in documenting resident incapacity properly, providing adequate linens, completing ordered laboratory tests, ensuring resident safety in seating, medically necessary use of psychoactive drugs, and adherence to hand hygiene during medication administration.
Complaint Details
Complaint reference #2-6048 was unsubstantiated with no related deficiencies cited; however, the investigation identified multiple deficiencies as noted.
Severity Breakdown
SS=D: 3
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to document the reason and expected duration for resident incapacity in medical records for two residents (#97 and #36). | SS=D |
| Failure to ensure wash cloths were available to residents when needed, as reported by two residents and observed by staff. | SS=E |
| Failure to complete ordered laboratory testing for four residents (#16, #54, #71, #73). | SS=E |
| Failure to provide adequate supervision to prevent accidents; resident #104 was observed sliding down in a geri-chair without proper positioning or foot support. | SS=D |
| Use of psychoactive medication (Seroquel) without documented medical necessity or adequate monitoring for resident #69. | SS=D |
| Failure of nursing staff to wash or sanitize hands between residents during medication administration, risking infection spread. | SS=E |
Report Facts
Facility census: 116
Residents sampled: 21
Residents with incapacity documentation issues: 2
Residents reporting wash cloth shortage: 2
Residents with incomplete lab testing: 4
Residents with supervision issues: 1
Residents with unnecessary drug use: 1
Nurses observed not washing hands: 2
Inspection Report
Life Safety
Deficiencies: 0
Mar 23, 2006
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2006
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-6033.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-6033 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 2, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5308.
Findings
The complaint investigation was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint reference #2-5308 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 12, 2005
Visit Reason
Paper revisit to review the facility's plan of correction related to previously identified deficiencies.
Findings
The document contains a summary statement of deficiencies and the provider's plan of correction, specifically addressing notification of residents' rights and services.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | Level C |
Report Facts
Event ID: 860Y11
Provider/Supplier Identification Number: 515189
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 26, 2005
Visit Reason
The inspection was conducted as a complaint investigation, substantiated with deficiencies cited, related to resident care and facility compliance.
Findings
The facility was found deficient in multiple areas including failure to adequately assess and monitor a resident using physical restraints after a fall, failure to provide necessary treatment and monitoring for residents with pressure sores, and failure to maintain proper infection control by placing soiled linen barrels near clean linen carts.
Complaint Details
Complaint reference #2-5174 was substantiated with deficiencies cited related to physical restraints, pressure sores, and infection control.
Severity Breakdown
SS=D: 2
SS=B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure that a resident using a lap buddy restraint after a fall was adequately care planned and monitored. | SS=D |
| Failure to ensure that a resident with pressure sores received necessary treatment and services to promote healing. | SS=D |
| Failure to follow infection control procedures by placing a barrel of soiled linen adjacent to an uncovered clean linen cart. | SS=B |
Report Facts
Number of sampled residents with deficiencies: 5
Number of stitches: 15
Pressure sore size: 6
Pressure sore depth: 3
Pressure sore size: 0.25
Pressure sore size: 3
Pressure sore size: 6
Time of observation: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding lack of assessment for restraint devices and infection control issues | |
| Licensed Practical Nurse | Completed skin assessments and was interviewed about pressure sore documentation and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 14, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as complaint 2-5158.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference: 2-5158. Unsubstantiated complaint record with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5120.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-5120 was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 10
Mar 10, 2005
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with federal regulations regarding resident rights, quality of care, resident assessment, and clinical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to honor resident advance directives, inadequate care and monitoring of hemodialysis access, failure to maintain resident personal space, incomplete resident assessments and care plans, lack of communication with dialysis center, improper medication administration, and incomplete clinical records.
Severity Breakdown
D: 6
E: 1
F: 2
G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to involve a resident in end-of-life decision making and follow advance directives as stated in her Living Will. | D |
| Failure to provide care and services to maintain patency of an arteriovenous (AV) graft for dialysis access resulting in loss due to infection. | G |
| Failure to create and maintain an environment assuring residents' personal space free from wandering residents. | E |
| Failure to document summary information from resident assessment protocols (RAPs) and rationale for care planning decisions. | F |
| Failure to develop comprehensive care plans describing services for residents with daily pain and those receiving hemodialysis. | D |
| Failure to communicate with dialysis center to develop and implement coordinated care plan for continuity of care. | D |
| Failure to assess resident prior to and after dialysis and chemotherapy treatments and administration of contraindicated medication. | F |
| Failure to ensure blood pressure was taken prior to administering Lopressor as ordered. | D |
| Failure to file laboratory reports from dialysis center in resident's clinical record. | D |
| Failure to maintain complete, accurate, and systematically organized clinical records including current assessments and physician orders. | D |
Report Facts
Facility census: 118
Sampled residents: 21
Medication holds: 14
Medication holds: 1
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 9
Mar 10, 2005
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident rights, quality of care, resident assessment, care planning, and clinical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to honor resident advance directives, inadequate care and monitoring of residents receiving hemodialysis, failure to maintain resident personal space, incomplete resident assessments and care plans, lack of communication with dialysis centers, administration of contraindicated medications, failure to assess residents before and after outpatient treatments, and incomplete and inaccurate clinical records.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
SS=G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to involve a resident in end-of-life decision making and follow the resident's advance directives as stated in her Living Will. | SS=D |
| Failure to provide care and services to maintain patency of an arteriovenous (AV) graft for dialysis access, resulting in loss of the graft due to infection. | SS=G |
| Failure to create and maintain an environment that assures each resident his/her own personal space free from wandering residents. | SS=E |
| Failure to document summary information for resident assessment protocols (RAPs) in the new computer software system. | SS=F |
| Failure to develop comprehensive care plans describing services for residents with daily pain complaints and those receiving hemodialysis. | SS=D |
| Failure to communicate with dialysis center to develop and implement a coordinated care plan for a resident receiving dialysis. | SS=D |
| Failure to provide services meeting professional standards of quality, including administering medication without checking blood pressure as ordered. | SS=D |
| Failure to file laboratory reports from dialysis center in resident's clinical record. | SS=D |
| Failure to maintain complete, accurate, and systematically organized clinical records, including missing assessments and updated physician orders. | SS=D |
Report Facts
Facility census: 118
Sampled residents: 21
Medication holds: 14
Medication holds: 1
Medication doses: 6
Inspection Report
Routine
Census: 118
Deficiencies: 3
Mar 9, 2005
Visit Reason
Routine inspection conducted to assess compliance with NFPA Life Safety Code standards and other regulatory requirements related to facility safety systems including sprinkler systems, extinguishing systems, and emergency power supply.
Findings
The facility failed to maintain the sprinkler system free of corrosion, failed to conduct monthly inspections of the rangehood extinguishing system, and did not maintain or properly document weekly inspections and monthly load testing of the emergency power generator system.
Severity Breakdown
SS=B: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Sprinkler heads under attached porch areas and in kitchen dishwasher room were corroded, failing to meet NFPA 25 standards. | SS=B |
| Rangehood extinguishing system lacked monthly inspection records from September 2004 to March 2005, violating NFPA 17A requirements. | SS=B |
| Generator system lacked documentation of weekly maintenance checks and monthly load testing at required parameters per NFPA 99. | SS=C |
Report Facts
Facility census: 118
Sprinkler heads corroded: 13
Generator tests required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding lack of monthly inspections and generator maintenance documentation |
Inspection Report
Routine
Census: 118
Deficiencies: 3
Mar 9, 2005
Visit Reason
The inspection was conducted as a routine survey to assess compliance with NFPA Life Safety Code standards and other regulatory requirements.
Findings
The facility failed to maintain the sprinkler system, rangehood extinguishing system, and emergency power supply system in accordance with NFPA standards. Corroded sprinkler heads were observed, monthly inspections of the rangehood extinguishing system were not documented, and generator testing and maintenance records were incomplete or missing.
Severity Breakdown
SS=B: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Sprinkler heads located under attached porch areas and in the kitchen dishwasher room were corroded, failing to meet NFPA 25 inspection and maintenance standards. | SS=B |
| Rangehood extinguishing system lacked monthly inspection records from September 2004 to March 2005, violating NFPA 17A standards. | SS=B |
| Generators were not inspected weekly or exercised under load monthly as required by NFPA 99; records were incomplete or missing. | SS=C |
Report Facts
Facility census: 118
Sprinkler heads corroded: 13
Generator tests required: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding lack of monthly inspections and generator testing records |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 3
Sep 22, 2004
Visit Reason
The inspection was conducted as a complaint investigation involving two complaint references (#2-4277 substantiated with no related deficiencies, and #2-4302 unsubstantiated with unrelated deficiencies).
Findings
The facility failed to maintain documentation of a resident's refusal of medical treatment and notification to the physician for one resident (#15) who frequently refused medications. Additionally, observations revealed inadequate housekeeping and maintenance issues in the adolescent residential area, including damaged carpet, missing bathroom fixtures, and personal belongings improperly stored.
Complaint Details
Complaint reference #2-4277 was substantiated with no related deficiencies cited. Complaint reference #2-4302 was unsubstantiated with unrelated deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Failed to ensure documentation of a resident's refusal of medical treatment and notification to the physician for resident #15. |
| Failed to maintain a safe and appropriate environment for adolescent consumers, including lack of alarms on outside doors and inadequate weekend night supervision. |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, bleach spots, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Resident census: 116
Medication refusal days: 11
Sample size: 15
Sample size: 3
Inspection Report
Census: 6
Deficiencies: 3
Sep 22, 2004
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations and to evaluate the adequacy of supervision and maintenance in the facility.
Findings
The facility failed to provide a safe environment for adolescent consumers due to lack of awake-night supervision on weekends and unsecured doors. Additionally, the facility did not ensure adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and personal belongings improperly stored. The facility also failed to follow documented actions to prevent accidents, as evidenced by a resident hitting their head on a handrail despite a prior incident and planned preventative measures.
Severity Breakdown
C 173: 1
C 174: 1
N 361: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of awake-night supervision on weekends and unsecured outside doors. | C 173 |
| The Center failed to ensure adequate housekeeping and maintenance, including damaged carpet, bleach spots, torn furniture, missing towel bars and toilet paper holders, and dirty sinks. | C 174 |
| The facility failed to follow documented action to prevent recurrence of accidents, specifically a resident hitting their head on a handrail despite prior incident and planned preventative measures. | N 361 |
Report Facts
Center Census: 6
Sample Size: 3
Number of residents sampled: 13
Resident identifier: 46
Observation time: 10
Observation time: 15
Date of accident report: Sep 19, 2004
Date for carpet replacement: Sep 30, 2004
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Aug 11, 2004
Visit Reason
The inspection was conducted as a complaint investigation (reference #2-4246) regarding substantiated complaints about staff treatment of residents, specifically concerning failure to protect residents from violent behavior by another resident.
Findings
The facility failed to adequately assess, monitor, and manage a resident (#116) with violent and aggressive behavior, which resulted in multiple assaults on other residents and threats that were not effectively addressed. The care plan was not revised despite repeated incidents, and the facility continued to place the aggressive resident with roommates, leading to injuries.
Complaint Details
Complaint reference #2-4246 was substantiated with deficiencies cited related to staff treatment of residents and failure to protect residents from abuse and neglect.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to take necessary action to protect residents and staff from a resident with violent behavior. | SS=G |
Report Facts
Facility census: 115
Bruise size: 12
Bruise size: 4
Bruise size: 1.5
Bruise size: 1
Bruise size: 1.2
Bruise size: 1.5
Scratch size: 2
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 8
Jul 22, 2004
Visit Reason
Complaint investigation related to substantiated complaints with deficiencies cited regarding resident care and facility compliance.
Findings
The facility was found deficient in multiple areas including unsafe self-administration of medications by a resident, failure to ensure call lights were within reach, improper use of bed alarms, inadequate social services addressing resident needs, incomplete treatment documentation, failure to prevent resident falls and injuries, insufficient nursing staff, poor infection control practices, and inadequate follow-up after a resident bite incident.
Complaint Details
Complaint reference #2-4223; substantiated complaint record with deficiencies cited.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=C: 1
SS=G: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Resident allowed to self-administer medications was unable to do so safely. | SS=D |
| Call lights not in reach for five residents; bed alarm not applied as ordered. | SS=E |
| Facility failed to provide medically-related social services addressing resident's psychosocial needs. | SS=D |
| Treatment records incomplete; treatments not always documented or verified. | SS=C |
| Failure to prevent injury from falls; inadequate supervision and care plan revisions. | SS=G |
| Insufficient nursing staff to provide adequate care and supervision. | SS=E |
| Poor infection control during dressing change; contamination of resident's door knob. | SS=D |
| Inadequate follow-up after resident bite incident; no post-exposure testing for bloodborne pathogens. | — |
Report Facts
Facility census: 116
Number of residents with call light issues: 5
Number of residents with fall-related incidents reviewed: 18
Number of residents affected by care plan communication issues: 6
Number of residents with documented deficiencies in nursing care: 14
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 1
Jun 11, 2004
Visit Reason
The inspection was conducted in response to a complaint (Complaint 2-4199) alleging that a male resident was physically and emotionally abusing female residents.
Findings
The facility failed to implement procedures to protect female residents from physical and emotional abuse by one male resident, Resident #9, who engaged in inappropriate sexual behaviors including fondling and groping female residents. Staff failed to adequately monitor or intervene to prevent these behaviors despite documented incidents and a care plan.
Complaint Details
Complaint 2-4199 was substantiated with a deficiency. The complaint involved Resident #9's inappropriate sexual behavior towards female residents, which was confirmed by interviews, observations, and medical record review.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to implement procedures to ensure female residents were free from physical and emotional abuse by one male resident. | SS=G |
Report Facts
Census: 120
Medication dosage increase: 100
Medication dosage previous: 75
Dates of behavioral incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Witnessed inappropriate behavior by Resident #9 and yelled at him but did not intervene further | |
| Administrator | Interviewed and acknowledged facility had not relocated Resident #9 to a more appropriate setting | |
| Assistant Director of Nursing | Interviewed and acknowledged facility had not relocated Resident #9 to a more appropriate setting | |
| Facility Nurse | Interviewed about medication administration for Resident #9 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 9, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4122.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-4122 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 5
Feb 11, 2004
Visit Reason
The inspection was conducted due to complaints related to resident safety, specifically concerning elopement and accidents involving residents, to assess compliance with quality of care and safety regulations.
Findings
The facility failed to ensure adequate supervision and implementation of safety recommendations for residents, resulting in one resident eloping and suffering mild hypothermia and abrasions, and multiple residents experiencing preventable injuries due to lack of proper care planning and safety device use.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving Resident #52's elopement and multiple residents' accidents and safety issues. The complaint was substantiated based on findings of inadequate supervision and failure to implement safety measures.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to conduct a complete resident count after an elopement alarm, resulting in a resident wandering along a busy highway and sustaining mild hypothermia and abrasions. | SS=E |
| Failure to implement recommended padding on wheelchair for Resident #68 to prevent skin tears. | SS=E |
| Failure to ensure Resident #29 wore geri gloves as ordered to prevent skin tears. | SS=E |
| Failure to properly attach personal alarms for Residents #75 and #8, preventing effective operation. | SS=E |
| Failure to install non-skid strips in Resident #71's room as recommended to prevent falls. | SS=E |
Report Facts
Residents sampled for elopement safety: 14
Residents sampled for accident prevention: 11
Skin tear size: 10
Skin tear width: 0.4
Resident #52 admission date: Admitted on 2003-08-26
Resident #52 body temperature during incident: 95
Baseline temperature for Resident #52: 98.2
Outdoor temperature range: 23 to 34 degrees Fahrenheit on date of elopement
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 10
Dec 11, 2003
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, care, treatment, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly document resident decision-making capacity, inadequate staff assistance with personal hygiene, incomplete criminal background checks for new hires, failure to revise care plans after significant resident changes, inaccurate and incomplete resident assessments, improper medication administration, failure to obtain ordered lab tests timely, inadequate prevention of pressure sores, failure to secure personal alarms properly, and unsigned physician orders.
Severity Breakdown
Level B: 1
Level C: 2
Level D: 5
Level E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to document specific reasons and expected duration for residents' incapacity to make decisions as required by state law. | Level C |
| Failure to provide assistance with personal hygiene as requested by Resident #31. | Level D |
| Failure to conduct statewide and multi-state criminal background checks for three of five newly hired employees. | Level D |
| Failure to revise Resident #23's care plan after a significant weight loss was identified. | Level D |
| Failure to complete minimum data set assessments accurately and to specify who completed each portion. | Level C |
| Failure to administer eye drops using proper technique and failure to obtain lab work as ordered for Residents #23, #77, and #117. | Level E |
| Failure to elevate Resident #117's heels and apply prescribed dressings to prevent pressure sores. | Level D |
| Failure to secure personal alarm properly for Resident #52, preventing proper function. | Level D |
| Failure to have physician sign and date monthly orders for Residents #44, #64, and #117. | Level B |
| Failure to obtain laboratory tests as ordered for Resident #48. | Level D |
Report Facts
Sampled residents: 21
Facility census: 118
Employees reviewed: 5
Residents with capacity documentation issues: 11
Residents with assessment issues: 21
Residents with medication/lab issues: 4
Residents with unsigned physician orders: 3
Inspection Report
Life Safety
Census: 118
Deficiencies: 2
Dec 11, 2003
Visit Reason
The inspection was conducted to evaluate the facility's compliance with NFPA 101 Life Safety Code standards, specifically regarding the facility's fire safety plan and emergency power system.
Findings
The facility failed to include a code phrase in the fire safety plan for use during fires or fire drills, and the emergency power system (generator) failed to start within the required time during testing, indicating non-compliance with NFPA 101 and NFPA 99 standards.
Severity Breakdown
SS=C: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility fire plan does not include a code phrase for use in the event of a fire or during fire drill rehearsals. | SS=C |
| The emergency power system (generator) failed to start within 90 seconds during a full load test, failing to meet NFPA 99 requirements. | SS=F |
Report Facts
Facility census: 118
Generator start time: 90
Required generator start time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding fire plan and generator issues | |
| Service Technician | Informed maintenance supervisor about generator solenoid issue |
Inspection Report
Deficiencies: 2
Mar 13, 2003
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident rights, notification of changes in condition, and staff treatment of residents, including reporting injuries and changes in resident status following hospitalization.
Findings
The facility failed to immediately notify the legal representative of a resident with significant changes in physical condition after hospitalization and failed to report injuries of unknown source for two residents in accordance with state law. Documentation of attempts to contact responsible parties was insufficient, and the facility did not comply with timely reporting requirements.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately notify the legal representative of a resident following significant changes in physical condition after hospitalization. | SS=D |
| Failure to immediately report injuries of unknown source for two residents in accordance with state law. | SS=D |
Report Facts
Sampled residents: 115
Pressure ulcer size: 8
Pressure ulcer size: 7
Pressure ulcer size: 11
Pressure ulcer size: 2
Bruises count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator | Interviewed regarding failure to notify legal representative and report injuries | |
| Director of Nurses (DON) | Interviewed regarding failure to notify legal representative and report injuries | |
| Facility Nurse | Interviewed regarding failure to report injuries | |
| Facility Social Worker | Documented contact with legal representative on 03/11/03 |
Inspection Report
Life Safety
Deficiencies: 0
Jan 9, 2003
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 1981 New Edition.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code requirements.
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 8
Nov 22, 2002
Visit Reason
Annual inspection of Fairmont Rehabilitation and Healthcare Center LLC to assess compliance with federal regulations including resident rights, staff treatment, resident assessments, quality of care, dietary services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to properly document legal surrogate designations, failure to report abuse allegations timely, failure to verify out-of-state employee registries, incomplete resident assessments and care plans, failure to follow bowel protocols for constipation, improper food storage temperatures, inadequate handwashing by dietary staff, and improper wound dressing techniques.
Severity Breakdown
SS=E: 5
SS=D: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to assure legal surrogates were designated in accordance with State law for 9 of 14 sampled residents. | SS=E |
| Failure to report two allegations of abuse immediately to the state surveying agency. | SS=E |
| Failure to verify out-of-state nurse aide registries for two new employees. | SS=E |
| Failure to document summary information regarding resident assessment protocols and decision-making for care plans for 19 of 24 sampled residents. | SS=E |
| Failure to develop comprehensive care plans for two sampled residents despite decisions to proceed to care planning. | SS=D |
| Failure to follow bowel protocol to prevent constipation for 4 of 14 sampled residents, placing them at risk for fecal impaction. | SS=E |
| Failure to maintain ham salad and pureed equivalent at proper temperatures during storage and serving; dietary personnel failed to use proper handwashing techniques. | SS=F |
| Failure to follow infection control procedure for clean dressing changes for one sampled resident, placing resident at risk for infection. | SS=D |
Report Facts
Facility census: 119
Residents sampled: 24
Residents with legal surrogate issues: 9
Residents with bowel protocol failure: 4
Employees with unverified out-of-state registries: 2
Days without bowel movement: 6
Temperature of ham salad: 50
Temperature of ham salad sandwiches: 46.4
Temperature of sandwiches in refrigerator: 52.4
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 5, 2002
Visit Reason
The document is a plan of correction related to a previously identified deficiency during a facility survey.
Findings
The facility was cited for failure to properly inform residents of their rights, rules, services, and charges as required by regulations.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | SS=C |
Inspection Report
Life Safety
Deficiencies: 0
Feb 7, 2002
Visit Reason
The inspection was conducted to determine the facility's compliance with the provisions of NFPA 101:12; Life Safety Code, 1981 New Edition.
Findings
Based on review of facility documentation, staff interview, performance testing, and observations, the facility was found to be in compliance with the Life Safety Code provisions.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 16, 2002
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide reasonable accommodations for residents' individual needs, including call light accessibility and bathroom access, as well as concerns about care planning and quality of care related to fractures and blood sugar monitoring.
Findings
The facility failed to provide reasonable accommodations for residents, including accessible call lights and bathroom access for a paraplegic resident. Additionally, the facility did not develop an appropriate care plan for a resident with a distal radius fracture and failed to properly monitor and notify physicians about abnormal blood sugar levels for another resident.
Complaint Details
The complaint investigation found substantiated issues including lack of reasonable accommodations for residents (call light accessibility and bathroom access), failure to develop a care plan for a resident with a fracture, and failure to ensure proper care and physician notification for abnormal blood sugar levels.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide reasonable accommodations for residents' individual needs, including call lights not within reach and lack of handicapped bathroom access for a paraplegic resident. | SS=E |
| Failure to develop a comprehensive care plan for a resident with a distal radius fracture, including proper splint care and skin care. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable physical well-being, including inadequate monitoring and physician notification for abnormal blood sugar levels. | SS=D |
Report Facts
Sampled residents: 21
Residents with call light issues: 7
Fingerstick monitorings exceeding normal lab values: 16
Inspection Report
Plan of Correction
Deficiencies: 1
May 17, 2001
Visit Reason
This document is a Plan of Correction submitted by Fairmont Rehabilitation and Healthcare Center LLC in response to deficiencies identified during a prior inspection.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing, but does not provide detailed findings within this page.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Provider/Supplier Identification Number: 515189
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 26, 2001
Visit Reason
The inspection was conducted in response to complaint #2-1088 regarding quality of care concerns related to pressure ulcer treatment for Resident #92.
Findings
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure sores for Resident #92, who had a stage II pressure ulcer with necrosis that was not properly dressed or managed, causing pain and worsening condition.
Complaint Details
Complaint #2-1088 was substantiated based on observations, medical record review, resident and staff interviews indicating inadequate care for a pressure ulcer.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary treatment and services to promote healing and prevent new pressure sores for Resident #92 with a stage II pressure ulcer. | SS=G |
Report Facts
Residents identified with pressure ulcers: 7
Pressure ulcer size: 3
Necrotic area size: 2.5
Last dressing change date: 2001
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 16, 2000
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with federal regulations regarding resident rights, quality of life, resident assessments, and care planning.
Findings
The facility was found non-compliant in several areas including failure to promote resident dignity and respect, inaccurate Minimum Data Set (MDS) assessments for multiple residents, and incomplete comprehensive care plans for residents with behavioral issues. Specific deficiencies included staff speaking disrespectfully to residents, entering rooms without permission, and failure to accurately document and address residents' behavioral symptoms in assessments and care plans.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assure residents were spoken to in a dignified manner and respect for privacy by staff entering rooms without knocking. | SS=D |
| Failure to ensure accurate Minimum Data Set assessments for residents exhibiting inappropriate behaviors. | SS=D |
| Failure to ensure comprehensive care plans with measurable objectives for residents' mental and psychosocial needs. | SS=D |
Report Facts
Sample size of residents reviewed: 21
Residents with inaccurate MDS assessments: 3
Residents with unsigned MDS assessments: 4
Residents without comprehensive care plans for mental and psychosocial needs: 2
Inspection Report
Life Safety
Deficiencies: 0
Nov 16, 2000
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101:12; Life Safety Code, 1981 New Edition.
Findings
The facility was found to be in compliance with the provisions of NFPA 101:12; Life Safety Code, 1981 New Edition based on the review.
Inspection Report
Deficiencies: 0
Feb 9, 2000
Visit Reason
The inspection was conducted based on review of facility documentation, staff interview, observations, and performance testing to assess compliance with physical environment provisions.
Findings
The facility was determined to be in compliance with the provisions of 483.70 Physical Environment.
Inspection Report
Life Safety
Deficiencies: 0
Feb 9, 2000
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101, Life Safety Code 1981 (Existing) for the facility.
Findings
The facility was found to be without waivers and in compliance with 483.70(a) of the Life Safety Code.
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 7
Jan 27, 2000
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, quality of care, medication management, and staff policies.
Findings
The facility was found deficient in multiple areas including failure to conduct criminal background checks on new employees, inadequate accommodation of resident needs in the restorative dining program, inappropriate medication administration practices, failure to monitor and manage unnecessary drug use, and failure of the pharmacist to report medication irregularities.
Severity Breakdown
Level B: 1
Level C: 1
Level D: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to implement written policies and procedures prohibiting mistreatment, neglect, abuse of residents, and misappropriation of resident property, including failure to conduct criminal background checks on new employees. | Level C |
| Failure to provide services to reasonably accommodate individual needs for a resident in the restorative dining program. | Level D |
| Failure to give appropriate treatment and services to maintain or improve eating abilities of a resident in the restorative dining program. | Level D |
| Failure to ensure each resident's drug regimen was free from unnecessary drugs and given without adequate monitoring or indications. | Level D |
| Failure to ensure medication error rates were below five percent, with multiple medication administration errors observed. | Level B |
| Failure to provide medication at the time ordered by the physician and failure to properly clean inhaler mouthpieces. | Level D |
| Pharmacist failed to report medication irregularities including drug interactions and unnecessary drug use for a resident. | Level D |
Report Facts
Facility census: 119
Personnel records reviewed: 5
Residents observed in restorative dining program: 6
Residents sampled for drug regimen review: 14
Medication error rate: 15
Medication errors observed: 6
Medications observed: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JW | Referenced in relation to failure to conduct criminal background checks and failure to provide appropriate dining accommodations | |
| JF | Referenced in relation to medication administration errors and failure to monitor drug regimens |
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