Inspection Reports for Prestige Care Center of Fairfield
400 Highland Street, IA, 525560588
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 31, 2025 found the facility in substantial compliance with all previously identified deficiencies corrected and no new deficiencies cited. Earlier inspections showed a pattern of multiple deficiencies related to resident rights, medication administration, staffing, infection control, and safety, including substantiated complaints about abuse reporting and environmental sanitation. Notable issues included an immediate jeopardy finding in February 2025 for failure to follow physician orders on warfarin administration, substantiated complaints of medication errors, inadequate staffing, and failure to timely report and investigate abuse allegations. Several complaint investigations were substantiated over time, while many others were found unsubstantiated. The facility appears to have made improvements recently, with the latest follow-up confirming correction of prior deficiencies and no enforcement actions listed in the available reports.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
252% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
59 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jul 31, 2025
Visit Reason
A revisit of the survey ending June 11, 2025, and investigation of complaints #1713975-C, #1713978-C, #2563059-C, #2572816-C, and facility reported incident #1713976-M was conducted from July 21, 2025 to July 31, 2025.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective July 10, 2025. Investigations of complaints and the facility reported incident did not result in deficiencies.
Complaint Details
Investigation of complaints #1713975-C, #1713978-C, #2563059-C, and #2572816-C did not result in a deficiency. Investigation of facility reported incident #1713976-M did not result in a deficiency.
Report Facts
Complaint numbers investigated: 4
Facility reported incident investigated: 1
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 15
Jul 10, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of complaints and reported incidents from June 2 to June 11, 2025.
Findings
The inspection identified multiple deficiencies related to resident rights, medication administration, privacy, dignity, abuse reporting, care planning, staffing, infection control, and safety. The facility failed to meet several regulatory requirements, including proper documentation, staff training, and implementation of care plans. A plan of correction was submitted with corrective actions to be completed by July 10, 2025.
Complaint Details
The inspection included investigation of complaints and self-reported incidents involving residents #15, #21, #42, #53, #61, and staff member #165. The facility failed to report some incidents timely and did not fully investigate allegations of abuse. Protective measures were implemented after the investigation.
Deficiencies (15)
| Description |
|---|
| Failure to ensure residents were treated with dignity and respect, including timely meal service and catheter dignity bag provision. |
| Non-compliance with medication administration and self-medication safety assessments. |
| Failure to properly document and communicate resident code status and advance directives. |
| Failure to maintain resident privacy and confidentiality, including inadequate privacy measures during care. |
| Failure to ensure appropriate use and monitoring of psychotropic medications. |
| Failure to report allegations of abuse timely and conduct thorough investigations. |
| Inadequate discharge planning and documentation for discharged residents. |
| Failure to provide sufficient nursing staff to meet resident care needs. |
| Failure to ensure residents received adequate care for pressure ulcers and prevention of pressure injuries. |
| Failure to ensure safe use and supervision of equipment and devices, including wheelchairs and oxygen tanks. |
| Failure to maintain sanitary kitchen conditions and proper food handling. |
| Failure to conduct timely and accurate assessments, care planning, and documentation for residents' health conditions. |
| Failure to ensure adequate staff training and competency in CPR and emergency procedures. |
| Failure to post required nurse staffing information and maintain accurate staffing records. |
| Failure to maintain a safe, sanitary, and comfortable environment for residents. |
Report Facts
Census: 59
Deficiencies cited: 15
Plan of Correction Completion Date: Jul 10, 2025
Audit frequency: 12
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 1, 2025
Visit Reason
A revisit of the survey ending February 18, 2025 and investigation of complaints #126911-C, #126953-C, #127210-C and #127308-C was conducted from March 25, 2025 to April 1, 2025.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 16, 2025. Complaints #126911-C, #126953-C, #127210-C and #127308-C were not substantiated.
Complaint Details
Complaints #126911-C, #126953-C, #127210-C and #127308-C were investigated and found not substantiated.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Feb 18, 2025
Visit Reason
Investigation of complaints #126153-C and #126226-C conducted from February 10, 2025 to February 18, 2025.
Findings
The facility failed to follow physician orders for warfarin administration, resulting in an immediate jeopardy to resident #3's health and safety. The complaint #126153-C was substantiated. The facility implemented corrective actions including staff education and policy review to ensure compliance.
Complaint Details
Complaint #126153-C was substantiated. The investigation found failure to follow physician orders for warfarin administration, causing immediate jeopardy to resident #3.
Severity Breakdown
IJ: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) - Facility failed to follow physician orders for warfarin administration, resulting in immediate jeopardy to resident #3. | IJ |
Report Facts
Census: 65
Dates of complaint investigation: February 10, 2025 to February 18, 2025
Correction completion date: 03/16/2025
Audit duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shilo Gainer | Administrator | Signed the report on 3-16-2025. |
| Staff A | Certified Medication Aide | Interviewed regarding warfarin administration and hold orders. |
| Staff B | Certified Medication Aide | Interviewed regarding warfarin administration and hold orders. |
| Staff C | Licensed Practical Nurse | Interviewed regarding warfarin administration, hold orders, and resident condition. |
| Staff D | Licensed Practical Nurse | Interviewed regarding warfarin administration, hold orders, and resident condition. |
| Staff E | Pharmacy Technician | Interviewed regarding pharmacy processes for warfarin orders and holds. |
| Staff F | Nurse Practitioner | Interviewed regarding resident #3's warfarin management and condition. |
| Director of Nursing | Director of Nursing (DON) | Provided explanations about medication order processes and education. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 26, 2024
Visit Reason
The document is a Plan of Correction related to a Complaint Survey that ended on October 29, 2024, addressing compliance issues at the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification effective November 22, 2024.
Complaint Details
The Plan of Correction follows a Complaint Survey ending October 29, 2024, indicating the complaint was addressed and compliance achieved.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Oct 16, 2024
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#123274-C, #123355-C, #123570-C, #123731-C, #123914-C) and facility self-reports (#124123-I, #124159-I) from October 16, 2024 to October 29, 2024.
Findings
The facility failed to maintain a safe, functional, sanitary, and comfortable environment as evidenced by poor housekeeping and unsanitary conditions in resident rooms, including dirty floors and pooled water. Resident interviews and staff observations confirmed these deficiencies. Complaint #123274-C was substantiated.
Complaint Details
Complaint #123274-C was substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain a clean and sanitary environment based on observations and interviews, including dirty floors, pooled water, and debris in resident rooms. |
Report Facts
Facility reported census: 62
Brief Mental Status (BIMS) score: 14
Brief Mental Status (BIMS) score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Housekeeper | Observed leaving Resident #5's room and cleaning activities |
| Staff A | Housekeeper Director | Interviewed about cleaning procedures and monthly cleaning records |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 17, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification of compliance effective September 17, 2024.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Aug 20, 2024
Visit Reason
The inspection was conducted as a result of complaints #122086-C and facility self-reports #122083-I from August 15, 2023 to August 20, 2024, to investigate alleged deficiencies related to pharmacy services and medication management.
Findings
The facility failed to complete shift change controlled substance counts with the required two licensed nurses, and medication cart keys were not securely stored, leading to missing narcotics. The facility was found to have substantiated deficiencies in pharmacy services and drug storage procedures.
Complaint Details
The visit resulted from complaints #122086-C and facility self-reports #122083-I. The facility self-report #122083-I was substantiated.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to complete shift change controlled substance counts with two licensed nurses as required by facility policy. | SS=E |
| Failure to ensure custody of medication cart keys, which were accessible to unauthorized personnel. | SS=E |
Report Facts
Facility census: 65
Missing doses: 30
Missing tablets: 2
Compliance date: 9172024
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 12, 2024
Visit Reason
The document is a plan of correction submitted by Prestige Care Center of Fairfield following a regulatory inspection, indicating substantial compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities as of 08/09/2024, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 13
Jun 27, 2024
Visit Reason
Annual recertification survey and investigation of complaint intakes #121165-C and #121694-I conducted from June 24, 2024 to June 27, 2024.
Findings
The facility was found not in compliance with multiple regulatory requirements including resident self-determination, notice requirements before transfer/discharge, accuracy of assessments, coordination of PASARR and assessments, care plan timing and revision, services meeting professional standards, quality of care, free of accident hazards, respiratory care, sufficient nursing staff, menus meeting resident needs, food safety requirements, and quality assurance and performance improvement (QAPI) program. Several deficiencies were repeated from prior surveys.
Complaint Details
Complaint #121165-C was not substantiated. Facility reported incident #121694-I was not substantiated.
Severity Breakdown
SS=D: 7
SS=E: 5
SS=C: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to give resident meal choices prior to meals for 1 of 1 resident reviewed (Resident #58). | SS=D |
| Failed to notify the Ombudsman of a resident's hospitalization for 1 of 2 residents reviewed (Resident #28). | SS=D |
| Failed to accurately code antiplatelet medication, insulin, and hospice services for 4 of 23 residents reviewed (Residents #21, #22, #25, and #34). | SS=E |
| Failed to follow PASARR Level II special recommendations and timely submission for 2 of 2 residents reviewed (Residents #2 and #34). | SS=D |
| Failed to ensure comprehensive individualized care plans accurately reflected resident's plan of care for 4 of 23 residents reviewed (Residents #22, #25, #28, and #60). | SS=E |
| Failed to ensure residents received medications as ordered and proper medication administration practices for 2 of 2 residents reviewed (Residents #33 and #45). | SS=D |
| Failed to follow-up after a resident had no bowel movement for 7 days and failed to adequately assess a non-pressure wound for 2 of 3 residents reviewed (Residents #3 and #51). | SS=D |
| Failed to keep a resident free from injury while repositioning resulting in a head injury for 1 of 3 residents reviewed (Resident #22). | SS=D |
| Failed to follow physician's order for continuous oxygen administration for 1 of 3 residents reviewed (Resident #12). | SS=D |
| Failed to have sufficient nursing staff to assist residents with eating, toileting, and call light response resulting in incontinent episodes for 4 of 10 residents reviewed (Residents #17, #33, #41, and #45). | SS=E |
| Failed to follow menu directions for pureed diet; pureed cornbread was missing for 1 of 1 observation. | SS=E |
| Failed to maintain kitchen in a sanitary manner and failed to test low temperature dish machine chemical and temperature levels. | SS=E |
| Failed to ensure an effective QAPI program to address previously identified quality deficiencies resulting in multiple repeat deficiencies. | SS=C |
Report Facts
Deficiencies cited: 13
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Medication Aide | Named in medication administration deficiency. |
| Staff B | Licensed Practical Nurse | Named in insufficient staffing and accident hazard findings. |
| Staff C | Certified Nurse Aide | Named in accident hazard findings. |
| Staff F | Certified Nurse Aide | Named in accident hazard findings. |
| Staff G | Certified Nurse Assistant | Named in respiratory care observation. |
| Staff H | Cook | Named in pureed diet preparation deficiency. |
| Staff J | Human Resources | Named in medication administration deficiency. |
| Staff K | Licensed Practical Nurse | Named in medication administration deficiency. |
| Staff L | Certified Nurse Aide/Certified Medication Aide | Named in bowel movement documentation deficiency. |
| Staff M | Registered Nurse | Named in wound care deficiency. |
| Staff N | Registered Nurse | Named in medication error incident. |
| Staff O | Registered Nurse | Named in wound care observation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 26, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective June 23, 2024.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 3
May 23, 2024
Visit Reason
The inspection resulted from an investigation of complaints #120055-C, #120126-C, #120995-C, and a facility reported incident #120056-I conducted from May 20, 2024 to May 23, 2024.
Findings
The facility was found deficient in quality of care related to failure to notify the physician of a resident's elevated blood glucose over 450 mg/dl, insufficient nursing staff response to call lights, and food safety violations including improper food temperature control and glove use during meal service.
Complaint Details
Complaints #120055-C and #120995-C were substantiated. Facility reported incident #120056-I and complaint #120126-C were not substantiated.
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to notify the physician when a resident's blood glucose was over 450 mg/dl for 1 of 3 residents reviewed (Resident #4). | Level D |
| Failed to answer a call light in less than 15 minutes for 1 of 3 residents reviewed (Resident #1) due to insufficient number of staff. | Level D |
| Failed to serve mandarin oranges at the appropriate temperature; failed to serve room trays at proper temperature; and failed to remove gloves after handling food. | Level E |
Report Facts
Residents reviewed: 3
Residents reviewed: 3
Census: 60
Blood glucose readings over 450 mg/dl: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Confirmed notification to doctor if blood glucose was above 450 mg/dl |
| DON | Director of Nursing | Stated nurse notified provider of elevated blood glucose and call light response times |
| Staff C | Certified Nurse Aide | Reported call lights needed answered within 15 minutes |
| Staff D | Certified Nurse Aide | Reported call lights needed answered within 5 minutes or as soon as possible |
| Administrator | Confirmed staff needed to document notification of elevated blood glucose and described call light notification process | |
| Staff A | Cook | Checked food temperatures prior to service and during meal service |
| Dietary Manager | Checked food temperatures and monitored dietary staff compliance | |
| Dietician | Informed about food temperature monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2024
Visit Reason
A complaint investigation was conducted for complaints #118847-C, #119026-C, #119247-C and a facility self-report #119108-I from April 1, 2024 to April 3, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for complaints #118847-C, #119026-C, #119247-C and facility self-report #119108-I; facility found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2024
Visit Reason
A complaint investigation for Complaints #118023-C and #118171-C was conducted from January 16, 2024 to January 29, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #118023-C and #118171-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 5, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective January 5, 2024.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Dec 18, 2023
Visit Reason
The inspection was conducted as a revisit following a prior survey ending November 1, 2023, and an investigation of multiple complaints (#116687-C, #117375-C, #117547-C) and a facility-reported incident (#117387-I).
Findings
The facility failed to report allegations of resident-to-resident sexual abuse and facial bruising of unknown origin in a timely manner for three residents. The investigation into the facial bruising was incomplete, lacking interviews with all staff who worked during the relevant period. The facility staff and administration did not consider the bruising incident reportable initially, attributing it to coughing and positioning, but the complaint was substantiated.
Complaint Details
Complaint #117375-C was substantiated. The facility failed to timely report and thoroughly investigate allegations of abuse and facial bruising for Residents #1, #2, and #3. Resident #2 was involved in an incident of placing his hand inside another resident's brief, which was not reported immediately. Resident #1 had unexplained facial bruising attributed to coughing and positioning, but the investigation was incomplete. The facility did not consider these incidents reportable initially.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to report allegations of resident-to-resident sexual abuse and facial bruising of unknown origin in a timely manner for 3 residents. | SS=D |
| Failed to thoroughly investigate facial bruising of unknown origin for 1 of 3 residents reviewed for inadequate nursing supervision. | SS=D |
Report Facts
Resident census: 66
Brief Interview for Mental Status (BIMS) score: 10
Brief Interview for Mental Status (BIMS) score: 8
Brief Interview for Mental Status (BIMS) score: 0
Bruise size: 4
Bruise size: 3
Bruise size: 3
Incident report number: 1285
Incident date: Dec 3, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Investigated Resident #1's facial bruising and determined it was related to coughing and positioning. |
| Staff C | Registered Nurse | Observed bruising on Resident #1, took pictures, reported to DON, and documented incident report. |
| Staff G | Certified Nursing Assistant | Reported Resident #2 placing hand inside Resident #3's brief and separated residents. |
| Staff A | Certified Medication Aide | Reported the incident involving Resident #2 and Resident #3 to Human Resources. |
| Staff D | Business Office Manager | Received report of incident involving Resident #2 and Resident #3 and coordinated reporting process. |
| Staff E | Certified Nurse Aide | Observed bruise on Resident #1 and reported to Staff B. |
| Staff F | Registered Nurse | Witnessed Resident #1 rub her neck forcefully when trying to expel phlegm. |
| DON | Director of Nursing | Interviewed staff and resident, managed investigation and reporting of facial bruising and abuse allegations. |
| Administrator | Assisted with follow-up investigation and interviews regarding Resident #1 facial bruising and abuse allegations. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Nov 1, 2023
Visit Reason
Investigation of Complaints #114342-C, #115870-C, #116362-C, and Facility Reported Incidents #115165-I and #115972-I conducted from October 23, 2023 to November 1, 2023.
Findings
The facility failed to ensure resident safety and prevent elopement for Resident #8, failed to ensure residents were free of significant medication errors affecting Resident #2 and Resident #3, and failed to comply with Life Safety Code regulations by improperly securing a fire exit door with a combination lock without Fire Marshall approval.
Complaint Details
Complaint #116362-C was substantiated. Facility Reported Incidents #115165-I and #115972-I were substantiated.
Severity Breakdown
SS=G: 1
SS=D: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure resident safety and prevent elopement for Resident #8 who eloped 0.7 miles from the facility. | SS=G |
| Failed to ensure residents were free of significant medication errors; Resident #2 received medication intended for Resident #3 causing delay in analgesic administration. | SS=D |
| Failed to comply with Life Safety Code regulations by applying a combination lock to a fire exit door without Fire Marshall approval, preventing the door from opening without a code. | SS=F |
Report Facts
Resident census: 68
Elopement distance: 0.7
Elopement risk score: 21
Pain scale: 3
Pain scale: 7
Medication doses: 4
Medication doses: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing (DON) | Completed Admission Assessment and Elopement Risk Assessment for Resident #8 |
| Staff L | Licensed Practical Nurse (LPN) | Administered medication in error to Resident #2 and documented medication error |
| Staff J | Dietary Manager | Found Resident #8 at gas station after elopement |
| Staff E | Licensed Practical Nurse (LPN) | Nurse on duty during Resident #8 elopement event |
| Staff G | Maintenance | Assisted in locating Resident #8 after elopement and involved in door alarm issues |
| Administrator | Facility Administrator involved in notification and response to Resident #8 elopement and door alarm issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2023
Visit Reason
A complaint investigation for Complaints #113999-C was conducted from July 3, 2023 to July 17, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #113999-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 9, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status and certification.
Findings
The facility was certified in compliance effective June 9, 2023, based on acceptance of a credible allegation of compliance and plan of correction. A Denial of Payment for new Medicare and Medicaid Admissions was imposed from April 25, 2023 to June 8, 2023.
Report Facts
Denial of Payment period: Denial of Payment for new Medicare and Medicaid Admissions imposed from April 25, 2023 to June 8, 2023
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 1
Jun 8, 2023
Visit Reason
The visit was a revisit of previous surveys ending March 20, 2023, and May 9, 2023, conducted to verify correction of prior deficiencies related to respiratory care.
Findings
The facility failed to ensure oxygen tubing was changed regularly according to professional standards and failed to transcribe the order for continuous oxygen to the Treatment Administration Record and care plan for 3 residents. Observations and record reviews showed lack of labeling and documentation of weekly oxygen tubing and humidifier bottle changes.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure oxygen tubing was changed regularly in accordance with professional standards and failed to transcribe the order for continuous oxygen to the Treatment Administration Record and care plan for 3 residents (#36, #15, #16). | SS=D |
Report Facts
Census: 60
Brief Mental Status (BIMS) score: 15
Brief Mental Status (BIMS) score: 13
Brief Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Interviewed regarding oxygen tubing change procedures and accompanied surveyor during observations |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 7
May 9, 2023
Visit Reason
Investigation of Complaints #112117-C, #112601-C, and #112652-C, and Facility Reported Incidents #111722-I, #112256-I, 112565-I, 112566-I, and 112603-I conducted May 1, 2023-May 9, 2023.
Findings
The facility was found to have multiple deficiencies including failure to respect resident rights, failure to notify family of changes in condition, inadequate care plan timing and revision, failure to implement fall prevention interventions, failure to prevent resident-to-resident altercations, failure to ensure quality of care, failure to maintain a safe environment, insufficient behavioral health staffing and interventions, and incomplete medical records.
Complaint Details
Complaints #112117-C and #112601-C, and facility reported incidents #111722-I, #112256-I, 112565-I, 112566-I and 112603-I were substantiated.
Severity Breakdown
SS=D: 4
SS=G: 2
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to treat a resident with respect by not allowing personal choice regarding door open for Resident #9. | SS=D |
| Failure to notify resident representative after a change in condition for Resident #1. | SS=D |
| Failure to create and implement fall interventions based on root cause analysis for Residents #2, #3, and #5 and failure to prevent Resident #7 from entering other resident's rooms. | SS=D |
| Failure to carry out adequate assessments and interventions for Resident #1 with a change in condition. | SS=D |
| Failure to ensure the resident environment remains free of accident hazards and adequate supervision to prevent accidents for Residents #2, #3, #5 and failure to ensure proper disposal of a needle. | SS=G |
| Failure to have sufficient staff with appropriate competencies and skills to provide behavioral health services and implement non-pharmacological interventions for Resident #7. | SS=G |
| Failure to maintain complete, accurate, and accessible medical records including thorough investigations for falls, resident exiting building, and resident-to-resident altercations. | SS=E |
Report Facts
Deficiency count: 7
Resident census: 64
BIMS score: 14
BIMS score: 5
BIMS score: 10
BIMS score: 5
BIMS score: 6
BIMS score: 5
BUN level: 122
Creatinine level: 7.1
Audit frequency: 5
Audit duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shilo Gainer | Provisional Administrator | Signed report and provided statements regarding resident rights and care plan interventions |
| Director of Nursing | Provided statements regarding resident rights, fall interventions, notification of changes, and stop signs for resident rooms | |
| Staff E | Former Administrator involved in resident door open issue | |
| Staff B | Certified Nursing Assistant | Observed transferring Resident #2 using mechanical lift |
| Staff F | Certified Nursing Assistant | Observed transferring Resident #2 using mechanical lift |
| Staff H | Licensed Practical Nurse | Reported finding a needle in bathroom |
| Staff G | Certified Nursing Assistant | Reported finding a needle in bathroom |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 17
Mar 20, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of substantiated complaints during March 13, 2023 to March 20, 2023.
Findings
The survey identified multiple deficiencies including failure to timely notify resident representatives of changes, incomplete Medicaid/Medicare coverage notices, employment of staff without proper licensure verification, failure to complete abuse/neglect training, untimely reporting of alleged violations, inaccurate assessments, incomplete care plans, medication errors, inadequate infection control, and incomplete COVID-19 vaccination documentation for staff.
Complaint Details
Complaint #107196-C and incidents #107579-I, #108740-I, and #111533-I were substantiated.
Deficiencies (17)
| Description |
|---|
| Failure to notify resident representative timely of change in condition for Resident #164. |
| Failure to provide Medicaid/Medicare Notice of Non-Coverage to Resident #56. |
| Failure to verify licensure for Certified Nurse Aide Staff C. |
| Failure to provide documentation of abuse mandatory reporter training for Staff N, RN. |
| Failure to timely report alleged staff tampering with morphine medication. |
| Failure to thoroughly investigate alleged violations of abuse and neglect. |
| Failure to complete accurate Minimum Data Set (MDS) assessments for multiple residents. |
| Failure to update care plans timely for residents with changes in condition. |
| Failure to meet professional standards for services provided including medication administration. |
| Failure to ensure resident environment free of accident hazards and adequate supervision. |
| Failure to provide respiratory care and tracheostomy suctioning according to orders. |
| Failure to maintain accurate pharmacy records and medication cross match. |
| Failure to ensure psychotropic drugs are used only when clinically indicated and monitored. |
| Failure to prevent significant medication errors including insulin administration. |
| Failure to prepare and serve food with proper nutritive value, appearance, and temperature. |
| Failure to maintain infection control practices including hand hygiene and replacement of resident basin. |
| Failure to ensure all staff are fully vaccinated for COVID-19 or follow facility policy for unvaccinated staff. |
Report Facts
Census: 64
Number of staff audited: 5
Compliance date: Apr 30, 2023
Number of residents reviewed for MDS accuracy: 4
Number of residents reviewed for care plan updates: 3
Number of residents reviewed for psychotropic drug use: 5
Number of residents reviewed for medication errors: 10
Number of residents reviewed for infection control audits: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 30, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on April 30, 2022, related to the facility's compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective April 30, 2022. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Mar 30, 2022
Visit Reason
The inspection was conducted to investigate complaint #102717 and facility reported incident #103513 from March 21-30, 2022. The complaint was substantiated.
Findings
The facility failed to meet transfer and discharge requirements, bed hold policy notification, permitting residents to return to the facility after hospitalization or therapeutic leave, and quality of care standards. Resident #1's case was specifically reviewed, revealing failures in documentation, notification, and care related to a hip fracture and discharge process.
Complaint Details
Complaint #102717-C was substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to meet all transfer and discharge requirements for 1 of 4 sampled for involuntary discharge (Resident #1). | SS=D |
| Facility failed to provide resident and/or resident representative written notice of bed hold policy for 1 of 4 sampled for bed hold notice (Resident #1). | SS=D |
| Facility failed to carry out policies that address bed-hold and return to the facility for 1 of 4 sampled for discharge (Resident #1). | SS=D |
| Facility failed to identify and assess a temporal contusion, decline in mobility, and pain in right leg/hip for 1 of 4 sampled for assessment and intervention (Resident #1). | SS=D |
Report Facts
Census: 63
Residents sampled: 4
Deficiencies cited: 4
Date of survey completion: Mar 30, 2022
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Mar 30, 2022
Visit Reason
The inspection was conducted to investigate complaint #102717 and facility reported incident #103513 from March 21-30, 2022. The complaint was substantiated.
Findings
The facility failed to meet transfer and discharge requirements, bed hold policy notification, permitting residents to return to the facility, and quality of care standards for Resident #1. The facility did not provide proper documentation, failed to notify resident or representative about bed hold policy, and did not ensure adequate care and assessment for the resident's injuries and condition.
Complaint Details
Complaint #102717-C was substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to meet all transfer and discharge requirements for 1 of 4 sampled for involuntary discharge (Resident #1). | SS=D |
| Failure to provide resident and/or representative written notice of bed hold policy for 1 of 4 sampled for bed hold notice (Resident #1). | SS=D |
| Failure to establish and follow written policy on permitting residents to return to the facility after hospitalization or therapeutic leave. | SS=D |
| Failure to ensure residents receive treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan. | SS=D |
Report Facts
Census: 63
Residents sampled: 4
Residents with deficiencies: 1
Random audit residents: 5
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 6
Dec 28, 2021
Visit Reason
The inspection was conducted as a result of complaint #101292, which was substantiated following an investigation from 12/16/21 to 12/28/21.
Findings
The facility failed to notify a resident's family or representative of a significant change in condition, failed to implement care plan interventions to prevent pressure ulcers, failed to administer medications within the physician-ordered time frame, and failed to assist a resident with activities of daily living. The facility also failed to maintain infection prevention and control measures.
Complaint Details
Complaint #101292 was substantiated following an investigation conducted from 12/16/21 to 12/28/21.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify resident's family or representative of a change in condition. | SS=D |
| Failure to develop and implement a comprehensive care plan to prevent pressure ulcers. | SS=D |
| Failure to administer medications within the physician-ordered time frame. | SS=D |
| Failure to assist a resident with activities of daily living to maintain good nutrition, grooming, personal and oral hygiene. | SS=D |
| Failure to maintain infection prevention and control program to prevent spread of communicable diseases. | SS=D |
| Failure to provide adequate catheter care and services to prevent catheter-associated complications. | SS=D |
Report Facts
Resident census: 69
Number of residents reviewed for pressure ulcers: 3
Number of residents reviewed for medication administration: 3
Number of residents reviewed for ADL care: 3
Number of residents reviewed for catheter care: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse (LPN) | Interviewed regarding resident's skin condition and care. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding resident's wound and care. |
| Staff A | Registered Nurse (RN) | Measured resident's wound and provided care instructions. |
| Staff J | Registered Nurse (RN) | Interviewed regarding resident's condition and care. |
| Interim DON | Director of Nursing | Provided statements on facility policies and corrective actions. |
Inspection Report
Renewal
Census: 64
Deficiencies: 12
Dec 7, 2021
Visit Reason
The inspection was conducted as a Recertification Survey, Complaint #96526, Facility Reported Incident #100967, and Mandatory #100337-M from November 29, 2021 to December 7, 2021. The visit included substantiated complaints and incidents.
Findings
The facility was found non-compliant in multiple areas including resident rights, notification of changes, abuse prevention and reporting, bed-hold policy, care plan timing and revision, professional standards, accident hazards, bowel/bladder incontinence care, nurse staffing information, and pharmacy services. Several deficiencies were substantiated with specific resident cases cited.
Complaint Details
Complaint #96526-C was substantiated. Facility Reported Incident #99880-I was substantiated. Allegations involved abuse including staff throwing a resident's doll and failure to notify local law enforcement of abuse.
Severity Breakdown
SS=D: 9
SS=E: 1
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to treat residents with dignity and respect; staff threw a resident's doll on the floor. | SS=D |
| Facility failed to notify resident's representative of a change in condition for a resident who fell. | SS=D |
| Facility failed to ensure completion of two hours of dependent adult abuse training for one staff member. | SS=D |
| Facility failed to notify local law enforcement when reporting an abuse concern. | SS=D |
| Facility failed to provide bed-hold notification for one resident. | — |
| Facility failed to include residents in care conferences and failed to update care plans after falls and for pressure ulcers. | SS=E |
| Facility failed to meet professional standards of quality by not following physician's orders for medication for one resident. | SS=D |
| Facility failed to provide oral care for dependent residents. | SS=D |
| Facility failed to implement interventions to prevent falls for one resident. | SS=D |
| Facility failed to ensure a resident with a catheter was assessed for catheter removal in a timely manner. | SS=D |
| Facility failed to post nurse staffing data and census on a daily basis for one day. | SS=C |
| Facility failed to provide accurate reconciliation of controlled substances and failed to safeguard medication counts. | SS=D |
Report Facts
Resident census: 64
Staff training hours: 2
Medication order dosage: 0.25
Medication bottle volume: 30
Medication bottle volume: 29
Medication bottle volume: 23
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2021
Visit Reason
Complaints #91874, #95318, #95503, and #96133 as well as Facility Self-Reported Incidents #95044 and #96140 were investigated from 3/3/21 to 3/17/21.
Findings
None of the complaint intakes or self-reported incidents were substantiated during the investigation.
Complaint Details
Complaints #91874, #95318, #95503, and #96133 as well as Facility Self-Reported Incidents #95044 and #96140 were investigated and none were substantiated.
Report Facts
Complaint numbers investigated: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 8, 2020
Visit Reason
A Focused Infection Control Survey and Complaint #94659 were completed on December 2 - 8, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Complaint #94659-C was not substantiated.
Complaint Details
Complaint #94659-C was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Nov 16, 2020
Visit Reason
The inspection was conducted as a focused infection control survey and complaint investigation related to complaints #93381, #92391, #92388, and mandatory complaint #92723.
Findings
The facility failed to ensure a resident environment free of accident hazards and adequate supervision to prevent accidents, specifically failing to safely transfer Resident #1, resulting in bruising and injury. The complaint #93381-C was not substantiated.
Complaint Details
Complaint #93381-C was investigated and found not substantiated. The investigation included multiple complaints and mandatory complaints related to infection control and resident safety.
Deficiencies (1)
| Description |
|---|
| Facility failed to safely transfer 1 of 5 sampled residents, resulting in bruising and injury to Resident #1. |
Report Facts
Census: 68
Brief Interview for Mental Status (BIMS) score: 8
Bruise size: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint #91873 were conducted by the Department of Inspection and Appeals from July 9 to July 21, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91873 was not substantiated.
Complaint Details
Complaint #91873 was investigated and found not substantiated.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Jan 8, 2020
Visit Reason
The inspection was conducted as an investigation of complaint #85490 regarding quality of care concerns at Sunny Brook Living Care Center.
Findings
The facility failed to ensure residents received treatment and care in accordance with professional standards for one sampled resident. Specifically, there were multiple omissions in wound treatment documentation and care for Resident #1, as evidenced by missing entries on the Treatment Administration Records (TAR) for various wound care treatments.
Complaint Details
The visit was complaint-related, investigating complaint #85490. The deficiency was substantiated based on record review and staff interview.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper wound treatment and documentation for Resident #1, including omissions on the Treatment Administration Records for multiple wound care treatments. | SS=D |
Report Facts
Census: 61
Treatment omissions: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 1/8/20 regarding investigation of Resident #1's wound care omissions; determined two nurses were responsible. |
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