Fairfield Post Acute Rehabilitation

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled residents, Resident 1 received care in accordance with professional standards of practice when facility staff did not follow physician orders and inaccurately documented medical notes during an emergent change of condition. These failures decreased the facility's potential to safely and effectively provide care to a resident with worsening health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was accurately reconciled before discharge when Resident 1 was sent home with the wrong insulin (a hormone produced by the body or given artificially to removes excess sugar from the blood) medication. This failure had the potential to cause sudden, severe hypoglycemia (low blood sugar) leading to confusion, seizures, or sudden death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly, when an unlabeled loose pill and three labeled blister packs (a type of unit-dose packaging with clear plastic bubbles (blisters) holding individual pills) were found on the bottom of a drawer and in the back of the drawers for one out of five sampled medication carts. These failures had the potential for medication error, misuse, or drug diversion.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store cookware pans and utensils in accordance with professional standards for food service safety when: Frying pans were stacked wet while stored away; and, Ladles and cake slicer were found wet while stored in the drawer. These failures had potential to cause food-borne illnesses in a highly susceptible population of 97 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 24 sampled residents (Resident 7, Resident 32, Resident 53, Resident 90) were offered an advance directive (a legal document where a competent adult specifies their future medical care wishes in the event they cannot communicate them themselves, often due to illness or injury). This failure had the potential to result in the residents' medical wishes not being honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to store resident food in a safe and sanitary manner in the refrigerators for residents for a census of 97 when:One opened bottle of soda stored past their use by date,Two bottles of opened salad dressings, and one fruit spread found unlabeled,One bag of loaf of bread was unlabeled, undated, and expired; and,Opened container of clam chowder with expired use by date. These failures had the potential to cause foodborne illnesses in a vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention measures were implemented for a census of 97 when:One facility staff did not sanitize the blood pressure (BP-measures the force of blood against artery walls) cuff in between two residents (Resident 2 and Resident 61). These failures had the potential to spread germs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 24 sampled residents (Resident 9) was free of unnecessary psychotropic medications (any drug that affects behavior, mood, thoughts or perception) when Resident 9 did not receive a psychiatric evaluation to determine if their psychotropic medication should be continued. This failure had the potential to result in the use of an unnecessary psychotropic medication that could cause adverse consequences. During a review of Resident 9's admission record (AR), the AR indicated Resident 9 was admitted to the facility in November 2025 with multiple diagnosis including dementia (a progressive state of decline in mental abilities). Resident 9's AR did not indicate a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms (rooms 1-9, 11-13, 15-21, 28-35, 37) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as:room [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform the weekly weights for one of the four sampled residents (Resident 1) per order and care plan. This failure exacerbated Resident 1's weight loss significantly.

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care services according to professional standards of quality for one resident (Resident 1), when Resident 1 arrived to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center with an empty oxygen tank. This failure decreased the facility's potential to safely provide Resident 1's oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in a sanitary environment when: 1. Ice packs for resident pain relief were stored in a refrigerator for food, 2. A dietary aide did not correctly test the sanitizer bucket, and 3. A cook did not correctly describe the cool down process. This failure could potentially lead to food-borne illness in vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the trash area clean. This failure could potentially result in an infestation of rodents or other vermin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe water temperatures at resident sinks when 6 of 22 resident bathroom sinks had water that was too hot to touch. This failure caused two residents to feel afraid of getting burns and one resident to yell out in pain when a hot wash cloth touched her hands.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure they were adequately staff when: 1.five out of five residents (Residents 64, 47, 295, 10 and Anonymous 1) complained of short staffing and were left sitting on their urine or feces for over an hour, 2. staff complaints of short staffing and difficulty completing their task timely. These failures resulted in residents feeling sorry for themselves, feeling frustrated, humiliated, embarrassed and worried about their safety and Resident 295 fearful she might get a wound infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan for falls when one of two residents sampled (Resident 48) fell which resulted in a hematoma (collection of blood beneath the skin) on her forehead and a laceration on her right foot. This failure had the potential to place Resident 48 at risk for insufficient provision of care and services when her care givers may be unaware of the plan of care for her wounds.

Inspectors wroteBased on interview and record review, the facility failed to implement all care measures specified in one resident's (Resident 345) Comprehensive Care Plan, when there was no documented evidence Resident 345 was turned and repositioned every two hours. This failure had the potential to delay wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident bedrooms provided at least 80 square feet of living space per resident in 29 multiple resident bedrooms. This failure had the potential for residents not to have enough personal space to live comfortably.

Inspectors wroteBased on observation, and interview, and record review the facility failed to ensure dietary staff had appropriate competencies and skill sets to carry out the function of the food and nutritional services when a cook did not follow a recipe for preparing pureed vegetables. This failure had the potential for a population of 71 residents, who received food from the kitchen, to be at risk for receiving meals that did not meet their nutritional needs.

Inspectors wroteBased on food production observations, resident and dietary staff interviews, and test tray evaluation the facility failed to prepare and serve meals that were palatable, and flavorful when: 1) mechanical soft (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor and requires less chewing) and pureed meals ( is an eating plan where all the foods have a soft, pudding-like consistency) were prepared in a manner that diluted the flavor and/or nutrient composition of food and 2) preparation of meals that were not flavorful or palatable which resulted in residents ordering food from outside sources. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention control practices when: 1. Staff did not perform proper hand hygiene during wound care for two sampled residents (Resident 27 and Resident 117), which included one resident (Resident 27) placed on Isolation for possible Clostridium difficile (a germ that causes severe diarrhea and stomach pain) infection. 2. High touch areas such as doorknobs and handrails were not frequently cleaned, disinfected, and sanitized. 3. Laundry barrels were not sanitized in between use. 4. Laundry staff did not remove PPE (Personal Protective Equipment) when moving from a dirty room to a clean room. 5. Nursing staff entered the laundry room from the dirty area to the clean area to get a clean clothing item for the resident. 6. Emergency water supplies were stored in unsanitary condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow respiratory care practices for four of four sampled residents (Resident 168, Resident 27, Resident 3, and Resident 117) when: 1. Two residents (Resident 168 and Resident 3) did not have Physician Order for oxygen therapy, and 2. Four residents (Residents 168, 27, 3 and 117) did not have documentation for nasal cannula (device used to deliver oxygen) changes. These failures had the potential to result in wrong administration of oxygen therapy, and the potentioal to promote infection in nasal cannulas that were not being changed.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual competency and skills check were conducted for licensed nurses and C.N.A.s (Certified Nursing Assistant). This failure had the potential to affect the quality of care provided to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure snacks were served at times in accordance with residents' needs, preferences, and requests when snacks were not provided or available to residents after the kitchen closed. Failure to meet resident food needs and requests could possibly lead to a decline in nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing was posted daily and in a prominent place that is readily accessible to residents and visitors. This failure resulted in out-of-date posting of nurse staffing and in a place where it was not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all Licensed Nurses follow the written direction for medication administration written by a Pharmacist to one of five residents, Resident 14. The medication called Viibryd (antidepressant) had a written directions on the label to be given with food. A Licensed Nurse administered the medication to Resident 14 on an empty stomach. This failure had the potential to result in poor absorption and poor effectiveness of the medication when taken on an empty stomach.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician/Nurse Practitioner's medication order and medication administration was adequately monitored for one of five residents, Resident 14, when: 1. The Assistant Director of Nursing (ADON), Management Staff G, did not put a date and time on the Physician's order after she reviewed the medication order for Metolazone (Metolazone is a diuretic medication (water pill)). 2. Management Staff G did not clarify with the ordering Physician or Nurse Practitioner when to initiate the first dose of the medication. 3. The initial dose of Metolazone was administered by a licensed nurse two days after it was ordered by the Physician/Nurse Practitioner. These failures had the potential to result in Resident 14's condition of Chronic Heart Failure (CHF) to worsen, which could lead to unnecessary illness and complications.