Fairburn Heights of Journey LLC

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Food Storage: Cold Foods, the facility failed to properly store opened, unopened and sealed food items in the walk-in freezer. The deficient practice had the potential to affect 87 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Routine Cleaning and Disinfection, the facility failed to ensure that Packaged Terminal Air Conditioning (PTAC) Units were free of dust and debris preventing proper filtration for heat and air in five of 15 resident (R ) (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) rooms, and failed to ensure nails protruding from the wall were removed to prevent accident hazards.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policies titled, MDS 3.0 Completion, the facility failed to correctly assess and identify intravenous (IV) access ordered and inserted the day after admission for one of 46 sampled residents (R) (R127). This deficient practice had the potential to confound care and monitoring of IV access, as well as the timely change of IV access.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Resident Assessment- Coordination with PASRR (Preadmission Screening and Resident Review) program, the facility failed to ensure that one of 46 sampled residents (R) (R7) was assessed for level two PASRR to the appropriate state-designated authority for evaluation and determination of specialized services (PASRR), if warranted. The deficient practice had the potential for R7's needs and services to go unmet.

Inspectors wroteBased on observations, staff and interviews, record review, and review of the facility's policies titled, Comprehensive Care Plans, the facility failed to follow the interventions of the comprehensive care plan for one of 46 residents sampled residents (R) (R12). This deficient practice could increase the risk of injury during a fall.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure physician orders were followed and documented for routine suprapubic catheter changes for one of four sampled residents (R) (R5). This deficient practice had the potential risk of infection and complications associated with prolonged indwelling catheter use when routine catheter changes were not completed and documented as ordered.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure proper maintenance of an oxygen (O2) concentrator (machine that produces O2) and failed to secure an O2 tank for one of 23 residents (R) (R58) receiving oxygen. This practice had the potential to cause respiratory distress, increased risk of respiratory complications, and injury

Inspectors wroteBased on record review, staff interviews and review of facility's policy titled, Emergency Staffing, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for six days, 04/05/2025, 04/06/2025, 05/03/2025, 05/24/2025, 05/25/2025, and 05/26/2025. This failure had the potential to affect all residents residing in the facility. The facility census was 110. Findings Include:Review of facility's policy titled Emergency Staffing Policy reviewed on 02/16/2024 revealed under section titled, Policy Explanation and Compliance Guidelines: The number of staff required for meeting resident needs on a daily basis are determined through the facility assessment. Schedules shall reflect sufficient staff with minimum use of scheduled overtime. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Hand Hygiene and Enhanced Barrier Precautions, the facility failed to use proper hand hygiene during wound care for one of 46 sampled residents (R) ( ) and failed to provide signage and PPE protocols for two of 46 sampled R's (R127 and R88). The deficient practice had the potential to cause the spread of infection to other residents and staff.

Inspectors wroteBased on observations, document review, and resident and staff interviews, the facility failed to ensure menus were prepared in advance for residents' diet orders. The facility failed to ensure menus indicated the serving size for each diet and whether each food item could be served for the diet. The failure placed all residents in the facility who receive oral meals from the kitchen at risk of nutritional problems and dissatisfaction with their meals.

Inspectors wroteBased on document review, staff interviews, and review of the facility's policy, the facility failed to ensure their infection control and prevention program included infection control surveillance documentation for the year 2024. This failure placed all residents at risk of the spread of infections.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure resident rooms and dining rooms were in good repair creating a homelike environment for 13 of 49 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) and the main Dining Room.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Date marking for food safety, the facility failed to ensure that food was properly labeled, stored, and prepared in a sanitary condition to prevent foodborne illness, failed to monitor and log daily temperature of refrigerator and freezer temperatures to ensure food was preserved per recommended guidelines, failed to monitor and log daily steam table temperatures, failed to monitor and log daily dishwasher temperatures, failed to test and log daily test sanitation solution in three-compartment sink. In addition, the facility failed to ensure the cleaning of appliances (stoves, ovens, fryers), countertops, food preparation areas, floor tiles, and ceilings. The deficient practice had the potential to affect 97 of 112 residents receiving an oral diet.

Inspectors wroteBased on observation, record review, staff interview, and review of the policy titled, Medication Administration the facility failed to ensure a medication error rate of less than five percent (5%) during medication administration for three of six Residents (R) (R44, R46, and R61). There were 35 opportunities observed resulting in three medication errors. The medication error rate was 8.57%. The facility census was 112.

Inspectors wroteBased on observations, record reviews, staff interviews, and a review of the facility policy titled, Menus the facility failed to ensure residents were served meals that were palatable, appetizing, and attractive. The deficient practice had the potential to affect 97 of 112 residents who consume an oral diet.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled, Disinfection of Bedpans and Urinals the facility failed to ensure a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by not labeling and properly storing bath basins, bed pans, and urinals in eight of 49 rooms (309, 313, 315,402, 404, 405, 407, and 408).

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled Medication Storage, the facility failed to assess four of 65 sampled residents (R) (R56, R44, R41, and R21) for the ability to self-administer medications before leaving medications at the bedside.

Inspectors wroteBased on observations, record reviews, staff interviews, and a review of the facility policy titled Menus, the facility failed to honor residents' rights to make choices related to meals and snacks. This had the potential to affect 108 of 112 residents who can consume meals.

Inspectors wroteBased on interview, record review, and review of the facility policy titled Bed Hold Policy, the facility failed to provide bed hold information, in writing, at the time of transfer to the hospital, or within 24 hours, for one resident (R), R154 of three sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to identify and submit a Preadmission Screening/Resident Review (PASARR) Level 2 review for one of three residents (R) (R60).

Inspectors wroteBased on record review staff interviews, and a review of the facility policy titled, Discharge Summary, the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medication for one of three residents (R) (R158).

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to provide a safe environment free from accident hazards for three of 64 residents (R) (R41, R9, and R24).

Inspectors wroteBased on observations, interviews, record review, and the policy titled, Oxygen Administration, the facility failed to provide effective oxygen therapy for four of 10 residents (R) (R47, R62, R21, and R100.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Hemodialysis, the facility failed to ensure communication was documented between the facility staff and dialysis staff to ensure pertinent information was being communicated for one of three residents (R) (R54) reviewed for dialysis.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled, Menus the facility failed to ensure meals and snacks are served at times per resident's needs, preferences, and requests. Nourishing alternative snacks were not provided for 97 of 112 residents to eat at non-traditional times or outside of scheduled mealtimes. The facility census was 112.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, it was determined that the facility failed to provide care and treatment to promote healing of pressure ulcers and prevent new ulcers from developing for one of three sampled residents (R) (R#101) reviewed for pressure ulcers. Specifically, the facility failed to complete weekly skin assessments to allow for identification and treatment of new areas of skin breakdown; failed to complete weekly measurements and assessments of existing pressure ulcers to track healing progress or determine if deterioration had occurred; and failed to complete pressure ulcer treatments per the physician's orders to promote the healing and prevent potential infection for R#101. The failures resulted in R#101's pressure ulcer deteriorating from a stage 2 wound to an unstageable wound. [...]

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure sanitary practices were followed in one of one kitchen to prevent potential food borne illness for residents. Specifically, the facility: 1. failed to ensure dishes were properly washed and allowed to air dry before stacking/storing. 2. failed to ensure food items were stored off the floor in the freezer. The failed practices had the potential to affect 94 residents who received food from the kitchen.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to thoroughly investigate an injury of unknown origin and report to the State Agency for one of two sampled residents (R) (R#101) reviewed for injury of unknown origin.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to revise a comprehensive care plan to include a post-fall intervention of a fall mat for one of four sampled residents (R) (R#101) reviewed for falls.

Inspectors wroteBased on observations, interviews, review of the facility policy, and record review it was determined that the facility failed to obtain a physician's order for one of three residents (R)(R#42) reviewed for the use of oxygen.