Inspection Reports for
Prestige Care Center of Fairfield

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.

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.

The facility had multiple deficiencies including failure to ensure resident dignity, incomplete self-medication assessments, inconsistent communication of code status, privacy violations during care, inappropriate use of psychotropic medications, failure to timely report abuse allegations, inadequate discharge planning, incomplete care plans, medication administration errors, insufficient bathing assistance, lack of CPR certified staff coverage, pressure ulcer care deficiencies, unsafe resident transfers, catheter care lapses, delayed call light responses, unsanitary kitchen conditions, failure to provide requested therapy services, incomplete facility assessment for specialized care, and unsanitary resident environment.

The facility had multiple deficiencies including failure to ensure resident dignity, incomplete self-medication assessments, privacy violations during care, improper use of psychotropic medications, failure to timely report abuse allegations, inadequate discharge planning, incomplete care plans, medication administration errors, insufficient bathing assistance, failure to address high blood sugar levels, unsafe transfer and supervision practices, improper catheter care, inadequate staffing response to call lights, failure to post nurse staffing information, unsanitary kitchen conditions, and failure to provide requested therapy services.

Complaint #126153-C was substantiated. The investigation found failure to follow physician orders for warfarin administration, causing immediate jeopardy to resident #3.

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.

The complaint investigation was substantiated. The facility was informed of the Immediate Jeopardy on 2/12/25, which began on 1/17/25 when warfarin was administered despite an INR of 6.7. The Immediate Jeopardy was removed on 2/13/25 after corrective actions.

The facility failed to hold or adjust warfarin doses as ordered after elevated INR lab results for Resident #3, leading to dangerously high INR levels and hospitalization. The facility implemented education and corrective actions to address the deficient practice.

The visit was complaint-related due to reports of poor housekeeping and unsanitary conditions. The complaint was substantiated based on observations and interviews.

The facility failed to maintain a clean and sanitary environment as observed in multiple resident rooms, with dirty floors, wet bathroom floors, and debris noted. Housekeeping staff interviews revealed inconsistent cleaning practices and missing monthly cleaning records.

Complaint #123274-C was substantiated.

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.

The visit resulted from complaints #122086-C and facility self-reports #122083-I. The facility self-report #122083-I was substantiated.

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.

The investigation was triggered by reports of missing narcotics and improper controlled substance counts. The complaint was substantiated with findings of missing Hydrocodone/APAP, Morphine sulfate, and Oxycodone doses, and failure to follow facility policy on narcotic counts and key custody.

The facility failed to complete shift change controlled substance counts with the required two licensed nurses and failed to ensure medication cart keys were only accessible to authorized personnel. Several missing narcotics were discovered during the investigation.

The facility had multiple deficiencies including failure to provide meal choices, failure to notify ombudsman of hospitalizations, inaccurate MDS assessments, incomplete care plans, insufficient staffing during meals, medication administration errors, inadequate wound care documentation, failure to follow oxygen therapy orders, unsanitary kitchen conditions, and ineffective QAPI processes.

Complaint #121165-C was not substantiated. Facility reported incident #121694-I was not substantiated.

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.

The complaint investigation substantiated issues with insufficient staffing leading to inadequate resident care and kitchen sanitation deficiencies.

The facility failed to provide adequate nursing staff during lunch to assist residents, resulting in incontinent episodes and delayed care. Additionally, the kitchen was found to be unsanitary with improper food storage and lack of dishwasher temperature and chemical testing.

Complaints #120055-C and #120995-C were substantiated. Facility reported incident #120056-I and complaint #120126-C were not substantiated.

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.

The facility was found deficient in notifying physicians of elevated blood glucose levels, timely response to call lights, and proper food temperature control and glove use during meal service. All deficiencies were assessed as causing minimal harm or potential for actual harm.

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.

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.

The complaint involved allegations of resident-to-resident sexual abuse between Resident #2 and Resident #3, and failure to report facial bruising of unknown origin for Residents #1, #2, and #3. The facility reported a census of 66 residents. The investigation found the facility delayed reporting the sexual abuse incident and failed to report facial bruising timely. The facility also failed to conduct a thorough investigation of the bruising for Resident #1. The complaint was substantiated with findings of minimal harm.

The facility failed to report an allegation of resident-to-resident sexual abuse in a timely manner and failed to report facial bruising of unknown origin for three residents. The facility also failed to thoroughly investigate facial bruising of unknown origin for one resident.

Complaint #116362-C was substantiated. Facility Reported Incidents #115165-I and #115972-I were substantiated.

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.

The complaint investigation was triggered by a resident elopement incident on 10/3/23 and a medication error involving incorrect administration of pain medication to Resident #2 instead of Resident #3. The facility was also found to have an unauthorized lock on a fire exit door.

The facility failed to prevent a resident's elopement by not identifying changes in condition and inadequate supervision. Additionally, a medication error occurred when one resident received another resident's pain medication, causing a delay in pain management. The facility also violated Life Safety Code by installing an unauthorized lock on a fire exit door.

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.

Complaints #112117-C and #112601-C, and facility reported incidents #111722-I, #112256-I, 112565-I, 112566-I and 112603-I were substantiated.

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.

The facility was found deficient in multiple areas including failure to honor resident dignity and personal choices, failure to notify family of changes in condition, inadequate fall prevention interventions and root cause analysis, failure to implement behavioral health care plans for residents with aggressive behaviors, improper disposal of needles, and incomplete medical record investigations.

Complaint #107196-C and incidents #107579-I, #108740-I, and #111533-I were substantiated.

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.

The facility had multiple deficiencies including failure to notify family of resident condition changes, incomplete staff licensure verification, delayed reporting of suspected abuse, inadequate supervision leading to resident elopement and falls, medication errors including narcotic mismanagement and medication administration errors, improper infection control practices, and incomplete COVID-19 vaccination tracking for staff.

The investigation was complaint-driven, including substantiated allegations of failure to notify family of condition changes, medication errors, and improper staff practices.

The facility had multiple deficiencies including failure to notify family of resident condition changes, incomplete Medicare/Medicaid notices, lack of licensure verification for staff, delayed reporting and incomplete investigation of morphine tampering allegations, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, medication administration errors including insulin pen priming and psychotropic medication management, failure to maintain narcotic medication logs accurately, food served at unsafe temperatures, improper infection control during incontinence care, and lack of COVID-19 vaccination documentation and contingency plans for staff.

Complaint #102717-C was substantiated.

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 #102717-C was substantiated.

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 #101292 was substantiated following an investigation conducted from 12/16/21 to 12/28/21.

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 #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.

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 #93381-C was investigated and found not substantiated. The investigation included multiple complaints and mandatory complaints related to infection control and resident safety.

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.

The visit was complaint-related, investigating complaint #85490. The deficiency was substantiated based on record review and staff interview.

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.