Inspection Reports for
Wishing Well Assisted Living Community at Fairmont

The initial survey found that the facility did not provide a safe environment for adolescent consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights. The plan of correction was reviewed and deficiencies were corrected as of May 14, 2025.

Investigation of Complaint #37917 dated 03/24/25. The complaint was substantiated and deficiencies were cited.

The complaint was substantiated with deficiencies cited including failure to notify the Secretary of a permanent change in the administrator within 10 days, failure to submit a license renewal application at least 90 days prior to expiration, and inadequate housekeeping and maintenance.

Complaint #26034 was substantiated. The complaint involved residents not being allowed to participate in group dining and activities during a COVID-19 outbreak despite negative test results and full vaccination status of residents and staff.

The facility failed to ensure residents' rights to make choices regarding daily activities, as group dining and activities were paused despite no positive COVID-19 cases. Additionally, inadequate housekeeping and maintenance were observed, including damaged carpets, missing bathroom fixtures, and unclean sinks.

The deficiency involved inadequate safety measures such as lack of alarms on outside doors and insufficient awake staff supervision on weekend nights. The plan of correction states that staff deployment changes will be implemented by July 1, 2004, to provide awake-night supervision during weekend shifts.

Complaint #25002 was substantiated. The breach involved a mass email sent on 09/30/20 to 98 families with visible email addresses. The facility reviewed communications for the past 60 days and found no further breaches. Resident X experienced no negative outcome.

The administration failed to maintain Resident X's confidentiality in a mass email sent to families, which included visible email addresses of all residents. The complaint was substantiated, but Resident X did not experience any negative outcome. The facility reviewed electronic communications and implemented corrective actions to prevent future breaches.

The facility failed to maintain confidential personnel records for the administrator and registered nurse on site, and failed to send pertinent medical information with residents upon transfer to hospital. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.

The facility failed to maintain the kitchen ceiling drywall patch and air supply vents, which were rusty and unsealed. Additional housekeeping deficiencies included personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and a dirty sink. Corrective actions and plans of correction were documented.

The facility was found deficient in ensuring all new employees received required orientation and training within 15 days of hire, including emergency procedures, resident rights, confidentiality, abuse prevention, and dementia-related training. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean areas observed.

Two deficiencies were identified during the annual licensure survey. A follow-up survey conducted on February 13, 2017, with a census of 30, confirmed that all deficiencies were corrected.

The facility was found deficient in completing the annual review of the disaster and emergency preparedness plan and maintaining the interior of the residence in clean and good repair, including a missing ceiling light cover in a resident bathroom.

The facility was found deficient in updating emergency contracts annually and maintaining the interior and exterior of the residence in clean and good repair, including issues with light fixtures, sprinkler escutcheons, ceiling tiles, and general housekeeping.

The facility was found deficient in multiple areas including inadequate housekeeping and maintenance, incomplete employee orientation and training, failure to maintain complete personnel records, incomplete resident health assessments and tuberculosis screenings, lack of physician orders for medications, and insufficient post-incident monitoring documentation. Corrective actions and plans of correction were provided for each deficiency.

The survey identified deficiencies including failure to maintain confidential personnel records with required tuberculosis screenings for two employees, and failure to update resident service plans to reflect current care needs for eight residents. Additionally, housekeeping and maintenance issues were noted in the facility environment.

The facility failed to ensure that residents with nursing care needs received comprehensive weekly assessments by a registered nurse. Documentation was inconsistent and incomplete, particularly regarding insulin management, skin integrity, neuropathy, and dietary compliance for residents #11, #12, and #26. The plan of correction was not fully implemented and deficiencies were repeated.

The facility was found deficient in multiple areas including employee orientation and training, nursing assessments, service plan updates, transfer documentation, dietary services, and housekeeping/maintenance. Several employees lacked required training documentation, nursing assessments were incomplete or missing, service plans did not reflect current resident needs, and dietary restrictions were not properly implemented or monitored.

Complaint Investigation #5218 conducted on October 7, 2009, involving allegations of improper medication administration by a nurse with license restrictions, admission of a resident with extensive nursing care needs, and failure to administer medications as ordered.

The facility failed to ensure accurate medication administration records, employed a nurse with license restrictions who administered narcotics and psychotropic medications contrary to those restrictions, admitted a resident requiring extensive nursing care without appropriate waiver, and failed to administer medications according to physician orders. Additionally, housekeeping and maintenance deficiencies were noted from a prior 2004 behavioral health survey.

The inspection found multiple deficiencies in the kitchen related to food safety and sanitation, including improper storage of wet rags, employee drinks near food, inadequate cooling of food, lack of sanitizing solutions, improper glove use, and mold accumulation. The environment also showed issues with housekeeping and maintenance.

The facility was found deficient in ensuring complete transfer/discharge summaries for residents, proper medication self-administration assessments, and management of physician-ordered therapeutic diets. Additionally, housekeeping and maintenance issues were noted in a behavioral health survey from 2004 referenced in the document.