Fairfield Senior Living & Rehabilitation LLC

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (R1) of 3 residents reviewed for medication administration in the sample of 6. This failure resulted in R1 not receiving his seizure medication as ordered for 5 days resulting in R1 experiencing a seizure that lasted 10 minutes and an emergency department visit. This past non-compliance occurred between 04/07/2026 and 04/13/2026. Findings Include:R1's admission Record documented an admission date to the facility of 03/14/2024 with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, type 2 diabetes mellitus, alcoholic cirrhosis of liver, chronic pancreatitis, hypothyroidism, hyperlipidemia, and epilepsy. [...]

Inspectors wroteBased on interview and record review the facility failed to implement appropriate interventions and supervision required to prevent an elopement for 1 (R2) of 3 residents reviewed for accidents in the sample of 6. The Findings Include:R2's admission Record documents an admission date to the facility of 12/01/2023 with diagnoses including Alzheimer's Disease, unspecified dementia, type 2 diabetes mellitus, chronic kidney disease, insomnia, and conductive hearing loss. R2's MDS (Minimum Data Set) with a date of 02/13/2026 documented Section C0100- Should Brief Interview for Mental Status be conducted? 0 was coded indicating that R2 is rarely / never understood and the assessment should not be completed. Section E-Behaviors documents under Wandering-Presence and Frequency documents the behavior was not exhibited. [...]

Inspectors wroteBased on interview and record review the facility failed to document and report a fall for 1 (R1) of 3 residents reviewed for accidents in the sample of 4. The past noncompliance occurred between [DATE] and [DATE]. The Findings Include:R1's admission record dated [DATE] documented that R1 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease without Dyskinesia, depression, sleep apnea, benign prostatic hyperplasia, essential hypertension, hypothyroidism, hyperlipidemia, and unspecified dementia. R1's MDS (Minimum Data Set) quarterly assessment dated [DATE] documented R1 has a BIMS (Brief Interview for Mental Status) score of 08 indicating R1 has moderate cognitive impairment. R1's Care Plan documents a focus area of Fall Risk - at risk for falls related to unsteady gait, interventions include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored at appropriate temperatures and lock medication cart. This failure has the potential to affect all 47 residents residing in the facility. Findings Include:On 7/23/25 at 11:40 AM, V8 (Licensed Practical Nurse/LPN) was observed administering insulin to R10. V8 gathered her supplies from the medication cart, left the cart unlocked, and entered R10's room. The cart was out of V8's visual control during the administration of the insulin. No observations were made of residents or staff near the unlocked cart. A list of ambulatory residents living at the facility dated 7/25/25 documented a total of 8 ambulatory residents. On 7/24/25 at 3:20 PM, V2 (DON) stated she re-educated V8 about the importance of keeping the medication cart locked when out of the nurses visual control. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dish machine was effectively sanitizing dishes to prevent cross contamination. This has the potential to affect all 47 residents residing in the facility. The Findings Include:On 7/22/25 at 9:00 AM, during the initial kitchen observation, the dish machine was being used to wash dishes. V6 (Dietary Aide) was asked to check the sanitizer level in the dish machine at this time. V6 was unable to get the test strip to register a sanitizer level, so V7 (Dietary Manager) got a new set of test strips to check the level. V7 was unable to get a level of sanitizer to register on the new strips and instructed V6 to begin washing dishes in the 3-compartment sink. On 7/22/25 at 11:00 AM, V7 stated that they are to check the sanitizer level 3 times a day prior to washing each meals dirty dishes. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the building had effective pest control for flies an gnats. This has the potential to affect all 47 residents residing in the facility. Findings Include: 1. On 7/22/25 on 9:00 AM, during the initial tour of the kitchen, the dish machine area had gnats and flies observed near the drain and the garbage disposal. At this same time, a wet towel was seen under the garbage disposal and crumbs and food debris were visible under the dish machine table as well. A this time, V4 (Dietary Aide) stated that the gnats and flies can get really bad down there if the floor is not kept clean and dry. V4 stated that they do pour bleach down the drain sometimes to help reduce the number of flies/gnats that accumulate down there. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that resident wheelchairs are cleaned and free of dirt and debris for 2 (R28 and R38) of 2 residents reviewed for clean equipment in a sample of 31. The Findings Include:On 7/23/25 at 10:00 AM, R38 was observed in his room sitting in his wheelchair. R38 was noted to be alert and oriented. The cushion of R38's wheelchair and the seat of the chair had a dried white substance and several crumbs from food dried in the same place. R38's handles were also dirty from where he had self propelled and dust and dirt were observed on the outside of his seat as well. R38 stated he thought the white substance may have been from his drinks spilling. R38 stated that he was unaware of the last time his chair was cleaned. On 7/23/25 at 10:30 AM, R28 was observed sitting in the common area by the nurse's station watching television. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a nutritional supplement in accordance with physician orders for one (R31) of three residents reviewed for dining in the sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light was in working order for 1 (R8) of 3 residents reviewed for resident call system in a sample of 12. Findings Include: R8's Face Sheet documented an admission date of 12/05/2024 with diagnoses that included weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, a unilateral primary osteoarthritis to right knee and personal history of transient ischemic attack. R8's Minimum Data Set (MDS) dated [DATE], documented under Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13, indicating R8 is cognitively intact. Under Functional Abilities for Self Care, the MDS documented that R8 requires staff assistance for toileting hygiene, showering/bathing, and dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 of 1 resident (R1) reviewed for falls in a sample of 12. This failure resulted in R1 becoming scared she would fall and anxious during the transfer and becoming afraid of of future mechanical lift transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide showers and timely assistance with showers and incontinence care for five of twelve residents (R1, R2, R3, R6, R7) reviewed for ADL (Activities of Daily Living) care in the sample of twelve.

Inspectors wroteBased on interview and record review, the facility failed to provide direct care staff in adequate numbers to ensure safe and timely resident care. This has the ability to affect all 34 residents living on the [NAME] and Daisy/Tulip halls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and evaluate potential hazards/risks and implement interventions to ensure safe transfers via mechanical lifts for 1 (R1) of 3 residents reviewed for accident hazards and injuries of unknown origin in the sample of 6. This failure resulted in R1 sustaining injuries of bruising to the tops of both feet and a hematoma under the nail of the right great toe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely reporting of potential abuse and neglect allegations, including an injury of unknown origin for 2 (R1 and R4) of 4 residents reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate and complete a timely and thorough investigation of an injury of unknown origin for 1 (R1) of 3 residents reviewed for abuse/neglect investigations in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care to 2 (R1 and R4) of 3 residents reviewed for Activities of Daily Living (ADL) care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a known elopement risk resident and complete wander guard tests to ensure a wander guard was working for 1 of 5 residents (R1) reviewed for supervision in a sample of 5. This failure resulted in R1 eloping from the facility, falling down three steps onto asphalt in R1's wheelchair, and sustaining a laceration to the head requiring sutures. The Immediate Jeopardy began on 6/18/24 at approximately 2:00 AM when R1 was unable to be located by facility staff and was found to have eloped from the facility and had fallen down three steps in R1's wheelchair. V1 (Administrator), V7 (Regional Clinical Director), and V8 (Vice President of Operations) were notified of the Immediate Jeopardy on 7/31/24 at 2:40 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to provide enough staff to supervise residents ensuring residents do not elope for 1 (R1) of 5 residents reviewed for supervision out of a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to provide enough staff to meet residents' needs and provide timely assistance with care. This failure has the potential to affect all 59 residents currently residing at the facility. Findings Include: The facility Midnight Census Report dated 6/16/24 documents 59 residents currently reside at the facility. 1. R1's Transfer/Discharge Report dated 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diarrhea, hypertension, clostridium difficile, flaccid neuropathic bladder, and morbid obesity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toilet transfers, is occasionally incontinent of urine, and frequently incontinent of bowel. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided timely for three residents (R1, R2, and R6) of 9 residents reviewed for incontinence care in the sample of 9. Findings Include: 1. R1's Transfer/Discharge Report with a print date of 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diarrhea, hypertension, clostridium difficile, flaccid neuropathic bladder, and morbid obesity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toilet transfers, is occasionally incontinent of urine, and frequently incontinent of bowel. R1's current Care Plan does not document a focus area for incontinence care/toileting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide additional nourishment as ordered in the form of nutritional supplements and fortified foods for five (R50, R31, R36, R44, and R45) of 12 residents reviewed for nutrition in a sample of 38. This failure resulted in R50 experiencing a significant weight loss of 17.5% in 3 months, and R31 experiencing a significant weight loss of 6.68% in 1 month or 8.58% in 3 months. Findings Include: 1. R50's Transfer/Discharge report documents an admission date of 01/26/24 with diagnoses including: Alcohol abuse with alcohol induced mood disorder, Alcohol Dependence with alcohol induced persisting dementia, Cognitive Communication Deficit, Unspecified Dementia, Wernicke's Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), and Mood Affective Disorder. [...]

Inspectors wroteBased on interview, record review and observation, the facility failed to provide enough staff to meet residents needs and provide timely assistance with care. This has the potential to effect all 67 residents residing at this facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the approved menu and failed to make a reasonable effort to provide menus in accordance with religious/cultural needs of residents. This failure has the potential to effect all 67 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food in a safe and sanitary environment and on sanitary dishes. This has the potential to effect all 67 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, homelike environment for 10 of 38 residents (R57, R113, R2, R15, R16, R19, R57, R214, R11, R22) reviewed for homelike environment in a sample of 38. On 5/20/2024 at approximately 9:45 AM, R2 was noted sitting in his bedside recliner. R2's bedroom floor had food debris and paper trash scattered about and trailed out into the hallway. On the morning of 5/20/2024, 5/21/2014 and 5/22/2024 at 2:00 PM, R2's bathroom was noted to have dark yellow odorous urine in the toilet bowl and two urine soaked adult briefs were noted in the bathroom trash can. One of the two urine soaked briefs were marked in ink with surveyor's initials on the edge of the brief on 5/20/2024 and the same ink mark was present on the brief on 5/21/2024 at 2:00 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers as scheduled for residents who require assistance for 4 (R113, R48, R11, R214) of 5 residents reviewed for assistance with Activities of Daily Living in a sample of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food at an appetizing temperature for 4 (R214, R38, R48 and R3) of 4 residents reviewed for palatable temperatures in a sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly admitted residents were offered to formulate Advanced Directives for three of five residents (R12, R62, and R113) reviewed for Advanced Directives in a sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to obtain a PASRR (Preadmission Screeening and Resident Review) level two screening for a resident with a newly diagnosed Severe Mental Illness for 1 (R11) of 2 residents reviewed for PASRR in a sample of 38. R11's Face Sheet dated 5/23/24 documents an admission date of 03/10/2014 with a diagnosis of Schizoaffective disorder. R11's OBRA (Omnibus Budget Reconciliation Act) I Initial Screen documentation dated 03/05/2014 lists Reasonable Basis to Suspect a Mental Illness .The individual has been formally diagnosed with a mental illness which substantially impairs the person's cognitive, emotional and /or behavioral functioning with a corresponding box that is marked No. R11's Physician Order documents an order on 08/04/22 to add Schizoaffective Disorder to R11's diagnosis list as evidenced by assessment with behaviors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement planned fall interventions to prevent falls for 1 (R1) of 5 residents reviewed for falls in a sample of 5. This failure resulted in R1 falling, fracturing his right hip and undergoing surgical repair of the fractured hip on 4/2/2024. This past non-compliance occurred from 3/31/2024 to 4/1/2024.

Inspectors wroteBased on interview and record review, the facility failed to administer regularly scheduled ordered pain medication for 1 (R1) of 5 residents reviewed for pain management. This failure resulted in R1 experiencing loss of sleep and significant pain to R1's shoulders, back, and knees due to missing R1's 2/5/24 pm dose of her regularly scheduled pain medication. This past noncompliance occurred between 2/05/2024 - 2/09/2024.

Inspectors wroteBased on interview and record review, the facility failed to ensure ordered pain medication was refilled in a timely manner for 1 (R1) of 3 residents reviewed for pharmacy services. This past noncompliance occurred between 2/05/2024 - 2/09/2024.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete weekly skin assessments, implement interventions to reduce pressure, and complete readmission assessments to identify any skin changes for 1 of 3 residents (R1) reviewed for being at risk for pressure injury in the sample of 3. This failure resulted in R1 developing pressure wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient staff to meet the needs of the residents. This has the potential to affect all 65 residents who currently reside at the facility. Findings Include: The Resident Census and Conditions of Residents dated 6/20/23 documents 65 residents reside in the facility. 1. R5's facility Transfer/Discharge Report with a print date of 6/23/23 documents R5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, seizures, diabetes, heart failure, anemia, difficulty in walking, and Parkinson's Disease. R5's MDS (Minimum Data Set) dated 4/25/23 documents a BIMS (Brief Interview for Mental Status) score of 06, which indicates a severe cognitive deficit. This same MDS documents R5 requires assist of two staff for transfers, toileting, and personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep food contact surfaces clean and sanitized to prevent cross contamination. These failures have the potential to affect all 65 residents in the facility. The Findings Include: On 6/20/23 at 9:30 AM, during the initial tour of the kitchen the following items were found: 1. The countertop slicer in the kitchen was covered with a plastic bag. When the bag was removed the bottom side of the blade and the base of the slicer were found to have dried food debris on them. At this time, V3 (Dietary Supervisor) stated that the plastic covering indicated that it is ready for use. V3 immediately instructed V12 (Cook) to clean and sanitize the slicer. 2. A measuring scoop was found in the bulk sugar bin with the handle laying in the sugar. V3 removed the scoop at this time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADL's) were provided per current standards of practice for 4 of 5 (R2, R5, R22, and R55) residents reviewed for ADL's in the sample of 69. Findings Include: 1. R5's facility Transfer/Discharge Report with a print date of 6/23/23 documents R5 was admitted to the facility on [DATE] with diagnoses that include cerebral infarct, seizures, diabetes, heart failure, anemia, difficulty in walking, and Parkinson's Disease. R5's MDS (Minimum Data Set) dated 4/25/23 documents a BIMS (Brief Interview for Mental Status) score of 06, which indicates a severe cognitive deficit. This same MDS documents under Section G, R5 requires assist of two staff for transfers, toileting, and personal hygiene. R5's current undated Care Plan documents a care area of (R5) voids in inappropriate places. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to prepare the pre-planned menu for 15 of 15 residents (R2, R5, R6, R9, R11, R12, R19, R29, R31, R42, R43, R47, R48, R50, and R54) reviewed for menus being followed in a sample of 69. The Findings Include: The lunch menu for 6/20/23 lists chicken patty on bun, peas and potato logs as the planned meal. On 6/20/23 at 10:30 AM, V12 (Cook) provided a menu revision that replaced carrots for the peas on the lunch menu. At this time, V12 was preparing the meals for the mechanical soft and puree residents. V12 was observed removing chicken from a pot of boiling water. V12 then mechanically chops the boiled chicken for the mechanical soft and blends to a smooth consistency for the puree diets. On 6/20/23 at 11:25 AM, V12 was observed preparing the steam table with the lunch items to be served. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were kept within reach for 1 of 24 (R22) residents reviewed for call lights in the sample of 69. Findings Include: R22's Transfer/Discharge Report with a print date of 6/23/23 documents R22 was admitted to the facility on [DATE] with diagnoses that include heart disease, heart failure, diabetes, and unspecified abnormalities of gait and mobility. R22's MDS (Minimum Data Set) dated 5/8/23 documents a BIMS (Brief Interview for Mental Status) score of 10, which indicates R22 has a moderate cognitive deficit. This same MDS documents under Section G, R22 requires two person physical assistance for transfers. R22's current undated Care Plan documents a care area of ADL (Activities of Daily Living) self-care performance deficit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the temperatures of the rooms were kept within a comfortable temperature range for 2 of 4 (R15 and R25) residents reviewed for temperatures in a sample of 69. Findings Include: 1. R25's facility Transfer/Discharge Report with a print date of 6/23/23 documents R25 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, shortness of breath, diabetes, hypertension, and morbid obesity. R25's MDS (Minimum Data Set) dated 5/17/23 documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R25 is cognitively intact. On 6/20/23 at 1:50 PM, V18 (Maintenance Director) stated the room temperatures should be less than 80 degrees. V18 stated the air conditioner motors are out (not working) in a few of the rooms. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 (R31) of 2 residents reviewed for abuse in a sample of 69.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report a resident-to-resident altercation to the Administrator or designee for 1 (R31) of 2 residents reviewed for abuse reporting in a sample of 69.

Inspectors wroteBased on interview and record review, the facility failed to monitor oxygen saturation levels as ordered by the physician for 1 (R70) of 1 residents in a sample of 16 reviewed for for oxygen saturation. The Findings Include: R70's admission record documents a date of birth as 4/17/91 and an admission date of 5/22/23. R70's order summary report dated with active orders for May of 2023 lists that oxygen saturation be monitored every day and night shift. This same report includes the following diagnosis: down syndrome, unspecified asthma, unspecified intellectual disabilities, acute respiratory failure with hypoxia, and pneumonia due to other streptococci. R70's weight and vital summary report during the length of his stay from 5/23/23 to a discharge date of 5/25/23 have no oxygen saturation levels documented. No oxygen saturation levels were documented in the nursing progress notes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide range of motion (ROM) exercises for 1 (R55) of 1 resident reviewed for ROM in the sample of 69. This failure has the potential to affect 64 residents (R1-R50, R52, R54, R55, R57-R63, R66, R173, R174, R321) who receive ROM exercises. Findings Include: An undated untitled list of all residents who receive restorative programs. This list documents (R1-R50, R52, R54, R55, R57-R63, R66, R321) have current orders for restorative programs. 1. R55's facility Transfer/Discharge Report with a print date of 6/23/23 documents R55 was admitted to the facility on [DATE] with diagnoses that include muscle spasm, spinal stenosis, and diabetes. R55's MDS (Minimum Data Set) dated 4/12/23 documents a BIMS (Brief Interview for Mental Status) score of 10, which indicates R55 has a moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hand hygiene was performed and personal protective equipment donned per current standards of practice, when providing incontinence care for 1 of 1 (R5) residents reviewed for infection control during incontinence care in the sample of 69. Findings Include: R5's facility Transfer/Discharge Report with a print date of 6/23/23 documents R5 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart failure, difficulty in walking, Parkinson's Disease, and unspecified intellectual disability. R5's MDS (Minimum Data Set) dated 4/25/23 documents a BIMS (Brief Interview for Mental Status) score of 06, which indicates R5 has a severe cognitive deficit. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure antibiotics were prescribed following current standards of practice for 1 of 1 (R25) residents reviewed for antibiotic stewardship in the sample of of 69. Findings Include: R25's facility Transfer/Discharge Report with a print date of 6/23/23 documents R25 was admitted to the facility on [DATE] with diagnoses that include Benign Prostatic Hyperplasia, urinary tract infections, obstructive and reflux uropathy, and overactive bladder. R25's MDS (Minimum Data Set) dated 5/17/23 documents a BIMS (Brief Interview Mental Status) score of 13, which indicates R25 is cognitively intact. R25's current undated Care Plan documents a Focus Area of indwelling catheter with diagnosis documented as neurogenic bladder. [...]