Fairacres Manor, Inc.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure safe holding temperatures for food items were maintained; -Ensure kitchen staff wore appropriate hair restraints when preparing and serving food to residents; and, -Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents nutritional needs. Specifically, the facility failed to: -Follow the weekly menu to ensure adequate nutrition was provided to the residents; and, -Ensure Resident #38 and Resident #10 were provided with the correct mechanically altered diet.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant dwell times (how long surfaces remained wet with disinfectant) were adhered to.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident care consistent with professional standards of practice, to prevent avoidable pressure ulcers (injuries) for two (#63 and #85) of four residents reviewed out of 39 sample residents. Resident #63 was admitted with dementia and muscle weakness and required extensive two-person assistance for mobility and transfers. This made the resident at risk for skin breakdown. The facility was aware of the resident's condition and failed to implement offloading, pressure relieving interventions until after the resident developed pressure ulcers. The resident had developed five facility-aquired pressure ulcers, two of which were stage 4, and two were unstageable. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions for one of one serving areas. Specifically, the facility failed to ensure: -Food temperatures of cold food was held at the proper temperature to reduce the risk of food borne illness; -Disinfecting chemicals were maintained at appropriate parts per million (PPM); -Dented canned food items were not put in the rotation, ready to be used and served: -Sugar, flour and utensils were stored appropriately; and -Food preparation surfaces were properly sanitized in the bistro area.

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection Specifically, the facility failed to: -Follow proper housekeeping protocols to prevent cross-contamination; -Ensure proper hand sanitation in rooms with residents with transmission based infections, and hand placement and hand hygiene when handling resident food; -Ensure proper use of personal protective equipment (PPE), including the changing of contaminating gloves, the donning and doffing of PPE and disposal of PPE in a room with a resident designated on isolation with contact precautions. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater to include three residents (#105, #12 and #38). Specifically, the medication pass observation error rate was 16.67 percent, or five errors out of 30 opportunities for error.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two out of two medication rooms and three out of five medication carts. Specifically, the facility failed to: -Remove expired medications from medication rooms and carts to prevent the use of expired medications; -Date medications when opened; and -Ensure medications were labeled with the medication name, dose, strength, expiration date, appropriate instructions and precautions, and route of administration.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide a reasonable accommodation of needs for one (#9) of one out of 39 sample residents reviewed for preferences and needs. Specifically, the facility failed to ensure a touch pad call light system was available to Resident #9 who had impaired function in the upper left and right hand and that his call light was within reach.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for staff convenience and not required to treat medical symptoms for one (#13) of one resident reviewed for restraints out of 39 sample residents. Specifically, the facility failed to: -Perform an initial assessment and subsequent quarterly assessments for the use of a lap belt; -Obtain a physician's order with a specific medical diagnosis for the use of a lap belt; -Obtain a consent from the resident's medical durable power of attorney (MDPOA) prior to the use of a lap belt; -Develop a monitoring system for the safe utilization of a lap belt; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the environment remained as free from accident hazards as possible for one (#99) of two residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure the metal bar on the Hoyer lift did not injure Resident #99's shins during transfers, resulting in multiple abrasions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure two (#60 and #48) of seven residents reviewed for restraints out of 39 sample residents, were free from restraints. Specifically, - The facility failed to timely and appropriately assess functional status and risk for elopement of Resident #60, who resided on the secure unit, and had additionally wander prevention device, watchmate; and - The facility failed to ensure an assessment was completed prior to applying a bolster mattress and barrier to Resident #48's bed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately, for one (#29) of three, out of 39 sample residents. Specifically, the facility failed to report Resident #29's injury of unknown origin to the administrator of the facility and to the State Survey Agency in accordance with State law. Cross reference F610- The facility failed to thoroughly investigate the injury of unknown origin.

Inspectors wroteBased on interviews and record review, the facility failed to have evidence all alleged violations of abuse and/or mistreatment, including injuries of unknown origin, were thoroughly investigated for one (#29) of three residents investigated for abuse out of 39 sample residents. Specifically, the facility failed to thoroughly investigate an injury of unknown origin for Resident #29. Cross reference F609- The facility failed to report an abuse allegation.

Inspectors wroteBased on interviews and record review the facility failed to complete a timely comprehensive and accurate assessment for one (#18) of three out of 39 sample residents. Specifically, the facility failed to complete the resident's readmission to the facility comprehensive assessment after Resident #18 returned from a hospital with a significant change in condition.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#18) of four reviewed for care plans out of 39 sample residents had a timely revision of the person centered care plan. Specifically, the facility failed to ensure the resident's comprehensive care plan was revised after a significant change of condition.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, the resident's care plan and the resident's choice for one (#32) of one resident reviewed for supplemental oxygen use out of 39 sample residents. Specifically, the facility failed to: - Ensure a current physician's order was in place for the resident's use of supplemental oxygen; - Fully develop a comprehensive care plan to address Resident #32's use and refusals of oxygen therapy.