Fairfield Village Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility did not have menus that were prepared in advance and were followed. Specifically, the menu had 4 ounces of Asian noodles and two small egg rolls for lunch and residents were served unmeasured Asian noodles and one small egg roll.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated, and sanitation buckets did not meet the required sanitation testing levels.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, if the events involved abuse or resulted in serious bodily injury, to the State Survey Agency (SSA) and Adult Protective Services (APS); and the results of the investigation were reported to the SSA within 5 working days of the incident. Specifically, for 3 of 42 sampled residents, the facility did not report to the SSA alleged violations involving abuse or neglect no later than 2 hours after the allegation was made or submit the results of the investigation to the SSA within 5 working days; and the facility did not report alleged violations to APS. Resident identifiers: 48, 66, and 67.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys. Specifically, for 11 of 42 sampled residents, medications were stored at temperatures below the manufacturer's instructions. Furthermore, the facility's Purified Protein Derivative (PPD), the testing solution used in the Tuberculosis (TB) screening process for new admits, was stored at temperatures below the manufacturer's instructions. Resident identifiers: 9, 10, 19, 30, 37, 59, 76, 77, 78, 79, and 80. Findings Included: On 5/27/26 at 10:10 AM, an observation was made of the facility's medication storage refrigerator with Registered Nurse (RN) 3, who confirmed the thermometer in the refrigerator read 32.5 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide at least three meals daily with no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may lapse between a substantial evening meal and breakfast the following day if a resident group agreed to this meal span. Specifically, the dinner and breakfast were served 15 hours apart and there was no substantial evening snack being offered.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 of 42 sampled residents, Enhanced Barrier Precautions [EBP] were not being implemented as ordered. Additionally, staff were not following hand hygiene procedures while serving meals. Furthermore, the facility's Tuberculosis (TB) screening process for new admits was inaccurate due to the testing solution (Purified Protein Derivative, or PPD) being compromised. Resident identifiers: 4, 38, and 28.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure the residents were free from misappropriation of resident property. Specifically, for 2 of 42 sampled residents, a staff member diverted narcotic medications. Resident identifiers: 68 and 73.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 42 sampled residents, a resident receiving an antidepressant for insomnia did not have hours of sleep monitored. Resident identifier: 60.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that in response to allegations of abuse and neglect the facility must have evidence that all alleged violations were thoroughly investigated. Specifically, for 1 of 42 residents sampled, the facility did not have evidence that an alleged violation of neglect was investigated. Resident identifier: 66.

Inspectors wroteBased on interview and record review it was determined that the facility did not document in the resident's medical record the information that was provided to the receiving provider which must include a minimum of the practitioner responsible for the care of the resident; the resident representative contact information; advanced directive information; comprehensive care plan; a copy of the resident discharge summary; and all necessary information to ensure a safe and effective transition of care. Specifically, for 1 of 42 sampled residents, the facility did not document in the resident's medical record the information conveyed to the receiving provider when the resident was transferred to the Emergency Room. Resident identifier: 48.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, for 1 of 42 residents sampled, the facility did not provide dining assistance for a resident that required such assistance and other residents were observed feeding the resident. Resident identifiers: 8 and 11.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 1 of 42 residents sampled, the resident developed skin breakdown at the facility and interventions were ordered but not implemented. Resident identifier: 54.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; for excessive duration; without adequate monitoring; in the presence of adverse consequences; or any combination of the above. Specifically, for 1 out of 42 sampled residents, the facility did not monitor the resident's insulin administration through his insulin pump system. Resident identifier: 54.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, for 1 out of 42 sampled residents, the resident was not provided the dietary preferences as requested to help manage his diabetes. Resident identifier: 54.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 2 out of 42 sampled residents, the facility prescribed antibiotic therapy to treat a Urinary Tract Infection (UTI) without obtaining a culture and sensitivity report to identify the organism and the antibiotic that organism was susceptible to. Resident identifier: 74 and 75.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that residents were offered the pneumococcal immunization unless medically contraindicated or declined. Specifically, for 1 out of 5 residents sampled, the resident signed the pneumococcal immunization form but the form did not indicate an administration or refusal of the vaccine. Resident identifier: 12.

Inspectors wroteBased on interview and record review it was determined, for 4 of 22 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, resident's psychotropic medications did not have a corresponding diagnosis or adequate indication for use. Resident identifier: 30, 83, 136 and 139.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cellular phones and a bluetooth speaker were stored on a drying rack used to store clean dishes and utensils in the kitchen, foods were stored inappropriately in the kitchen freezer, and staff did not serve food in a sanitary manner. Findings Include: On 1/6/24 at 9:25 AM, an observation was made of the drying rack next to the dish machine in the kitchen. On one of the shelves there was a bluetooth speaker and two cellphones with charging cords stored on the drying rack. The drying racks also had clean dishes and cooking utensils stored on the racks. On 1/6/24 at 9:32 AM, an observation was made of the kitchen freezer. There was a box of frozen blueberries open to the air. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a licensed nurse was observed to touch medication with contaminated gloves, alcohol swabs were placed on unclean surfaces prior to use, and used lancets were not disposed of in the sharps container. Resident identifier 85.

Inspectors wroteBased on interview and record review it was determined, for 1 of 22 sampled resident, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, there was no documentation regarding a resident experiencing a change in condition prior to passing away. Resident identifier: 30.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident was admitted with pressure ulcers [PU] and treatments were not provided according to physician orders. In addition, physician's orders were not the same as the wound clinic orders. Resident identifier: 9.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 22 sampled resident, the facility did not ensure that pain management was provided to residents who required services consistent with professional standards of practice and the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, a resident complained of uncontrolled pain and the facility had not reassessed her pain. Resident identifier: 83.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 22 residents, that the facility did not ensure that the resident's drug regimen was adequately monitored. Specifically, a resident was administered a medication used to treat hypertension when the resident's blood pressure was outside of parameters set by a physician's order. Resident Identifier: 24 Findings Include: Resident 24 was admitted [DATE] with diagnoses which included intertrochanteric fracture of left femur, fracture of the lower end of the left radius, essential (primary) hypertension, and hyperlipidemia. Resident 24's medical record was reviewed from 1/6/25 through 1/8/25. Resident 24's physician orders and Medication Administration Record (MAR) were reviewed from December 2024 through January 2025. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that its antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed a course of antibiotic therapy for a urinary tract infection without a culture and sensitivity report to verify that the organism was susceptible to the antibiotics ordered. Resident identifier 7.