Fair Haven Shelby County

Inspectors wroteBased on staff interview, observation, policy review, and record review, the facility failed to ensure food was served and stored in a safe and sanitary manner. This had the potential to affect all 64 residents who receive food from the kitchen. The facility census was 64.

Inspectors wroteBased on medical record review, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure a resident was properly transferred from a recliner chair to a bed by a Hoyer (mechanical Lift). This resulted in Actual Harm when the Hoyer lift tipped over during transfer by Certified Nursing Assistant (CNA) #200 and Resident #55 hit her face on the floor. Resident #55 sustained facial fractures, a subdural hematoma (bleeding between brain and outer covering), and a facial laceration that required medical transport by helicopter and hospital admission. This affected one (#55) of three residents reviewed for accidents. The census was 65.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure prescription medication was stored in a locked secured location and not within reach of the residents. In addition, the facility failed to ensure medications were labeled for opening, labeled for expiration, disposed of when expired and stored only with medications. This had the potential to affect all 62 residents in the facility who received medications. The facility census is 62.

Inspectors wroteBased on observation, staff interview, review of the facility menu, and review of the policy, the facility failed to ensure all residents received a balanced and nutritious meal. This had the potential to affect six residents (#01, #02, #19, #31, #26, and #53) who receive a pureed diet and did not receive bread or the desert, as well as all of the residents, who did not receive the desert. Resident #28 was identified as not receiving anything by mouth and is not affected. The facility census was 62.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure the kitchens were maintained in a clean and sanitary condition and foods were stored in a manner to avoid contamination and spoilage. The facility also failed to ensure the dishes were sanitized when using the dishwasher. Furthermore, the facility failed to maintain the ice machines in the smaller kitchen areas in a sanitary manner. This had the potential to affect all residents but one (#32) who received foods prepared in the kitchens. The facility census was 62.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a full-time Licensed Nursing Home Administrator was available at least sixteen hours weekly. This had the potential to affect all 62 residents in the facility. The faciltiy census was 62.

Inspectors wroteBased on record review and staff interview, the facility failed to have a comprehensive Quality Assurance Performance Improvement Program (QAPI). This had the potential to affect all 62 residents in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) took action and investigated underlying causes and factors contributing to problems. This had the potential to affect all 62 residents in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) committee met on a regular basis. This had the potential to affect all 62 residents in the facility.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain a pest-free environment. This had the potential to affect all residents (except Resident #32) who receive food served from the kitchen. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure the care plans were updated to reflect the current physician order, change in diagnosis and include interventions. This affected five (#9, #26, #41, #46, and #54) of 23 residents reviewed for care plans. The facility census was 62.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility staff failed to sign out narcotics when administered. This affected seven (#4, #7, #11, #20, #22, #26, and #43) of 62 residents in the facility randomly observed during medication cart review. The facility census was 62.

Inspectors wroteBased on medical record review, observations, staff interviews, review of medication inserts, and policy review, the facility failed to ensure medication were administered per physician orders and medications were documented when administered. This affected 16 (#4, #6, #7, #11, #15, #17, #18, #22, #26, #31, #32, #35, #43, #53, #61, and #115) of 62 residents in the facility. The facility census was 62.

Inspectors wroteBased on observation, staff interview, and review of the policy, the facility failed to ensure the refrigerator used by family to store foods brought in from outside for residents was maintained in a clean manner. This had the potential to affect 44 (#03, #04, #05, #06, #07, #08, #10, #11, #12, #13, #15, #16, #18, #20, #21, #22, #23, #26, #28, #30, #31, #33, #34, #35, #36, #38, #40, #42, #43, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #57, #59, #115, #116, #165, and #215) of 44 residents who utilized the refrigerator The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, resident interview, observation, review of the Sani-Cloth Bleach wipes container instructions, review of glucometer manufacture's recommendations, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to ensure hand hygiene was completed during a pressure ulcer dressing change for Resident #49; failed to ensure recommendations for enhanced barrier precautions (EBP) were initiated for Resident #26; failed to ensure gloves were worn during assistance with food for Resident #17 and #56; and failed to ensure glucometer was properly cleaned for Resident #115. This affected four residents (#17, #26, #49, and #56), with the potential to affect a limited number of resident who received assistance with meals, glucometer checks or were on enhanced barrier protection. The census was 62.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure residents were treated with dignity, when staff stood over residents while providing assistance with eating. This affected three (#2, #37, and #41) of three residents reviewed for feeding assistance. The facility census was 62.

Inspectors wroteBased on observations, resident and staff interviews, and review of the policy, the facility failed to maintain a homelike environment for the residents. This directly affected two (#28 and #115) of 62 resident rooms observed. The facility census was 62.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure medication administered was for an appropriate diagnosis. This affected one (#9) out of five residents reviewed for unnecessary medications. The facility census was 62.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the comprehensive assessment was completed accurately to include a diuretic for one (Resident #9) and included falls without injury for one (Resident #40). This affected two (#9 and #40) of five residents reviewed for comprehensive assessments. The facility census was 62.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure the comprehensive care plan was initiated to include contractures. This affected one (#32) of 23 residents reviewed for comprehensive care plans. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, observations and policy review, the facility failed to ensure dependent residents were provided personal hygiene. This affected two (#26 and #45) residents reviewed for activities of daily living (ADL). The facility census was 62.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the policy, the facility failed to ensure a Resident #46 reviewed for activities of daily living, had a hand splint applied as ordered. The facility further failed to ensure wound assessments were completed for a non pressure sore for Resident #40. This affected two (#40 and #46) of 21 residents reviewed for quality of care. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview, nurse practitioner interview, observations and policy review, the facility failed to ensure identified wounds were assessed, measured and documentated on discovery and pressure relieving devices were in place. This affected three (#1, #13, and #49) of three residents reviewed for pressure ulcers. The facility census was 62.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure the correct liquid nutritional liquid tube feeding supplement was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility census was 62.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure tube feeding container was labeled with what solution was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility censes was 62.

Inspectors wroteBased on the medical record review, staff interviews, and policy reviews, the facility failed to address complaints of pain when reported. Additionally, the facility failed to monitor the effectiveness of routine pain medication. This affected one resident (#12) of two residents revealed for pain management. The facility census was 62.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the care plan was followed for dementia treatment when the facility failed ensure medications being used was for dementia and an attempt to reduce the use of psychoactive medication was made. This affected one (#9) of four residents reviewed for dementia care. The facility census was 62.

Inspectors wroteBased on medical record review, observations, staff interviews, and policy review, the facility failed to ensure antibiotic use was necessary for one (#40) and failed to make recommendations for appropriate medication use for one (#9) This affected two (#9 and #40) of six residents reviewed for medication regimen review. The facility census was 62.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure antibiotic use was appropriate after a wound closed. This affected one (#40) of five reviewed for unnecessary medications. The facility census was 62.

Inspectors wroteBased on medication record review, observations, staff interviews, and policy review, the facility failed to ensure a medication error rate was below 5%. A total of 34 opportunities were observed with five errors for a error rate of 14.71%. This affected three (#17, #61, and #115) of four residents observed for medication administration. The facility census was 62.

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to ensure a resident receiving antibiotics was being tracked and monitored for use. This affected one (#40) of 8 reviewed for infection control. The census was 62.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure the Survey Book was updated with current surveys and located in an area visible to residents, visitors. This had the potential to affect all 62 residents in the facility. The facility census was 62.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure daily nurse staffing was posted daily and readily available for residents and visitors at any given time. This had the potential to affect all 62 residents. The facility census was 62.

Inspectors wroteBased on medical record review, review of a facility self-reported incident (SRI), staff and Detective #40 interviews, and policy review, the facility failed to thoroughly investigate an injury of unknown injury. This affected one (#11) out of three residents reviewed for injuries of unknown origin. The facility census was 57.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to develop a comprehensive care plan to address the amount of assistance a resident required with activities of daily living (ADL's). This affected one (#11) out of three resident reviewed for ADL assistance. The facility census was 57.

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to assess a resident and complete a post fall investigation after a resident experienced a fall. This affected one (#11) out of three residents reviewed for falls. The facility census was 57.

Inspectors wroteBased on record review, observation, and resident, family, and staff interview, the facility failed to ensure they had a qualified professional activities director and activities were provided to the residents as scheduled. This affected two residents (#45 and #63) of four residents reviewed for activities. This had the potential to affect all residents except for the 18 residents identified by the facility who usually decline to attend activities. The facility census was 67.

Inspectors wroteBased on record review and staff interview, the facility failed to administer medications per physician order. This affected one (Resident #63) of three residents reviewed for medication administration. The facility census was 67.

Inspectors wroteBased on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected four (#2, #3, #17, and #25) out of the four residents reviewed for medication administered as ordered. The facility census was 66.

Inspectors wroteBased on observations, staff interviews, medical record reviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 33 opportunities or six percent (%) medication error rate. This affected two (#2 and #17) out of the three residents observed for medication administration. The facility census was 66.

Inspectors wroteBased on medical record review, observation, staff interviews, and policy review, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#53) out of three residents reviewed for incontinence care. The facility census was 66.

Inspectors wroteBased on observations, staff interview, observation, and review of facility recipes, the facility failed to make pureed food to the correct texture and failed to follow a recipe to make the pureed food. This had the potential to affect six (#5, #15, #20, #24, #38, and #53) residents who have orders for pureed food. Facility census was 75.

Inspectors wroteBased on observations, staff interview and policy review, the facility failed to safety store food items in the refrigerator, freezer, and dry storage areas. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain covered and clean trash receptacles in the kitchen. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75.

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to serve food at a palatable temperatures. This has the potential to affect all 96 residents residing in the facility who are receiving food from the kitchen. The facility census was 96.

Inspectors wroteBased on review of facility records, staff interview and facility policy review the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96.

Inspectors wroteBased on review of facility records, staff interview and facility policy review, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to promote facility-wide monitoring for the appropriate use of antibiotics. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96.

Inspectors wroteBased on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed implement their abuse policy to ensure injuries of unknown origin were immediately reported to the to administrator/designee and to the state agency as required and to ensure injuries of unknown origin were thoroughly investigated. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96.

Inspectors wroteBased on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to immediately report injuries of unknown origin to administrator/designee and to the state agency as required. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96.

Inspectors wroteBased on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to thoroughly investigate injuries of unknown origin. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96.

Inspectors wrote3. Resident #65 was admitted to the facility on [DATE] with a readmission to the facility on [DATE] with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease, dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of Resident #65's annual assessment dated [DATE] revealed the resident scored a three on the 'Brief Interview for Mental Status (BIMS) indicating she had severe cognitive impairment and exhibited no behaviors. She required supervision of one person physical assistance for bed mobility and toileting. She required extensive assistance of one person for personal hygiene and dressing. She was occasionally incontinent of urine and always continent of bowel. She received an antidepressant all 7 days of the assessment period. used a walker for ambulation. [...]

Inspectors wroteBased on medical record review, pharmacist and staff interview and facility policy review, the facility failed to ensure the licensed pharmacist reported medication irregularities to the attending physician, medical director and the Director of Nursing. This affected five (#31, #64, #65, #68 and #87) out of five residents reviewed for unnecessary medications. The facility census was 96.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to provide written notification of transfer or discharge to the resident and the resident's representative. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to provide written notification of the bed hold policy to the resident or resident representative at the time of discharge to the hospital. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96.

Inspectors wroteBased on medical record review and staff interview, the facility failed implement a a dietary recommendation and physician order to increase a dietary supplement for a resident with a history of a significant weigh loss. This affected one (#91) out of two residents reviewed for significant weight loss/nutrition. The facility census was 96.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure meals were served under sanitary handling conditions for Resident #122. This affected one (#122) randomly observed resident receiving a hall tray on the Sycamore hall. The facility census was 96.