Fairmont Rehabilitation Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in food handling, storage, and preparation areas for 53 residents who received meals from the kitchen when:1. Debris was present inside the clean utensils drawer;2. Mold was found inside a bag of cherries stored in the refrigerator;3. Cereal container lids were found loose;4. An opened box of iced tea bags in the dry goods area contained a plastic bag with a hole;5. Four spice containers were observed with lids that were open and could not be closed;6. Two large spice containers with screw-top lids were not tightly sealed;7. The casserole scalloped potatoes box was not properly sealed;8. Inconsistent food labeling was observed, including multiple opened liquid seasonings and sweetener that lacked open-by-dates; 9. Wet snack containers were found stacked in a cabinet;10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote, maintain, and protect the dignity and privacy for one of eighteen sampled residents (Resident 5) when: 1. Certified Nursing Assistant (CNA) 1 did not fully close the privacy curtain during a bed bath, resulting in Resident 5's body being exposed and visible from the hallway; and, 2. Resident 5's nephrostomy (a thin, flexible tube is inserted through the skin of your lower back directly into your kidney to drain urine) drainage bag (urinary bag) was not covered with a dignity bag (privacy bag). These deficient practices resulted in unnecessary exposure of Resident 5 during care and had the potential for loss of privacy and dignity, and increased psychosocial distress (embarrassment, anxiety and feelings of humiliation).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 18 sampled residents (Resident 68) when Resident 68's call light (devices used to contact staff for assistance) was not within his reach. This failure placed Resident 68 at increased risk for unmet care needs, delayed staff response, falls, and increased the potential for accidents or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to act upon the concerns brought forth from the Resident Council (a group of residents that meet and discuss concerns monthly) when Resident Council concerns of call lights not being answered timely, call lights being wrapped around the bed frame, staff speaking another language, and staff not fully completing Activities of Daily Living (ADL- these are the fundamental, routine self-care tasks individuals perform daily such as eating, bathing, dressing, toileting, and moving around) care before leaving the room were not addressed by the facility in a timely manner. This failure resulted in residents declining to attend the Resident Council meeting scheduled on 3/24/26 and feeling that issues brought forth in Resident Council meetings were not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall intervention for 1 of 18 sampled residents (Resident 8), when fall mat was not placed at Resident 8's bedside. This failure had the potential for Resident 8 to sustain further falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete records for one of eighteen sampled residents (Resident 5) when, Resident 5's allergy to Levaquin (an antibiotic medication used to kill bacteria causing illness) was not updated in Resident 5's allergy profile, Resident 5 was ordered and administered Levaquin, and there was no documentation regarding communication with the ordering provider regarding the allergy, no documentation of an IDT (interdisciplinary team; a group of healthcare professionals) meeting discussing the medication allergy, or monitoring of any adverse reactions to the medication. This deficient practice had the potential to place Resident 5 at risk for adverse reactions and the care and services provided would not be known across all disciplines to assist in making medical decisions for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 53 residents when Resident 67's urinal (portable, handheld containers designed for men with limited mobility to urinate while in bed or seated) was not labeled with identifying information. This failure had the potential to spread infection and cause health problems to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS- a comprehensive assessment and screening tool) for 1 of 18 sampled residents (Resident 6), when Resident 6's oxygen therapy section was documented inaccurately. This failure had the potential to result in an inaccurate reflection of Resident 6's health status and the risk for confusion in Resident 6's plan of care.

Inspectors wroteBased on interview, and record review, the facility failed to submit a summary of investigation for an alleged resident to resident altercation to the Department within five (5) working days, as required, for one of three sampled residents (Resident 1). This failure placed Resident 1 at risk for further resident to resident altercations.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive care plan (written plan that guides staff on daily care and safety based on the resident's needs) for one of three sampled residents (Resident 1) to address Resident 1's frequent and extended use of a shared bathroom, which delayed other residents' access to the bathroom. This failure resulted in dissatisfaction among those residents and placed Resident 1 at potential risk for further altercations with other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (a serious lung infection) and other opportunistic waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 54 when: a. The facility did not complete and document a facility-wide assessment of potential Legionella growth areas to include flow chart, b. The facility did not implement adequate control measures, c. The facility did not establish sufficient monitoring protocols; and, d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of four residents (Resident 2) when Resident 2, who was at high risk for falls, fell when she was left in the bathroom unattended on 8/5/24. This failure had the potential to result in Resident 2 sustaining injury including fractures (broken bones) and decreased well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff served the correct meal portions for two of four sampled residents (Resident 2 and Resident 3) when, 1. Resident 2 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. 2. Resident 3 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. This failure had the potential to contribute to unplanned weight gain which could negatively impact the health and wellbeing of Resident 2 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage and production in accordance with professional standards of food safety for the 56 residents who received prepared food from the kitchen when: 1. Open food packages (one bag of bran cereal, one bag of biscuit mix, and a five-gallon storage bin with about two-gallons of rice) were not labeled with a use by date; and, 2. Wet plate covers were stacked together. These failures had the potential to expose residents to food borne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use of facility owned smart phones (also known as cell phones) for communication with medical providers regarding resident's Protected Health Information (or PHI, refers to any individually identifiable health information about a resident) with a census of 56 residents. This unsafe practice could compromise residents' private medical information and violate residents' health information privacy and confidentiality.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies) and one out of six medication carts (a mobile cart stored medication and supplies for immediate use), and medication refrigerator when: 1. Medication Cart 2 in Station 2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems); 2. Medication Closet 1 in Station 1, in the active storage areas, stored expired test tubes (A blood test tube is a sterile, vacuum-sealed tube used to collect and store blood samples for medical testing); and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety of bed side medication storage and use for 1 out of 10 residents (Resident 24) observed for medication administration based on facility's policy and medical doctor's orders. This failed practice resulted in unauthorize use of medications without a doctor's order in the facility, unsafe handling, and storage of medications in a room shared with another resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe cleaning and sanitization of shared glucometer (a device used to measure blood sugar) in-between resident care for two residents out of nine residents observed for medication administration (Resident 39 and Resident 10) based on facility's policy and manufacturer specifications. This failure had potential to spread infection among residents and compromise resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prescription medication delivery manifests (delivery manifest, also known as a shipping manifest, is a legal document that listed all items being transported in a shipment) which included narcotic controlled medications (medication with risk of abuse including opioids) were signed by licensed staff upon delivery from the provider pharmacy for a census of 56 residents. This failed practice may contribute to unsafe medication handling and risk of drug diversion (unlawful use or abuse of medication).

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs) for one of five residents (Resident 44) selected for unnecessary medication use when: 1. Resident 44's documented diagnosis of bipolar disorder (a chronic mood disorder which causes intense shifts in mood, energy levels and behavior) in the medical record for use of aripiprazole (a drug used to treat mental health issues) was not reflected in the medical doctor's progress notes, History and Physical (H&P), and previous hospitalization record; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 56 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in two out of 10 residents (Resident 5 and Resident 10) during medication administration observation. These failures could contribute to unsafe medications use, medication error, and not following the doctor's orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 412) was free from significant medication errors when vitamin D3 (supplement for low vitamin D levels in the blood) oral capsule 50,000 UT (UT-units is a unit of measurement) was administered daily from 10/26/24 to 12/26/24. This deficient practice placed Resident 412 at risk of vitamin D toxicity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff followed infection prevention practices and the required Enhanced Barrier Precaution (or EBP, an infection control strategy used in healthcare settings, particularly nursing homes, to reduce the spread of infection by requiring healthcare workers to wear gowns and gloves during high-contact resident care activities) guideline when the Intravenous (or IV, Into the Vein) line was used to administer IV antibiotic in one out of 10 residents observed for medication administration (Resident 47). This failed practice could contribute to unsafe medication use and spread of infection into Resident 47's blood stream.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform and document baseline and follow-up measurements of a PICC Line (peripherally inserted central catheter: a long, flexible tube inserted into one of the veins in the upper arm and used to deliver medication) external length and right upper arm circumference (distance around upper arm) for one of 16 sampled residents (Resident 54). This failure had the potential to result in Resident 54 having unidentified complications of right arm swelling and, dislodgement, occlusion, and leakage of the PICC line when it was not monitored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure E-kits (emergency medications) were replaced in a timely manner when medications were removed for a census of 55. This failure had the potential risk for residents not to receive medications in a timely manner and worsen their medical conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dental services were provided for one of 16 sampled residents (Resident 3) in a timely manner, when there was no follow up regarding Resident 3's authorization for a set of dentures for over four (4) months. This failure resulted in delay of dental services for Resident 3 and placed the resident at risk for oral pain related to inability to effectively chew foods and had the potential risk for unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 16 sampled residents (Resident 25) received an accurate assessment, reflective of the resident's status at the time of the assessment, including hearing assessment. Resident 25 had hearing loss and used hearing aids, however, the Minimum Data Set (MDS, an assessment and care screening tool) did not code the use of hearing aids. This failure contributed to facility's inability to develop and implement an individualized care plan related to Resident 25's use of hearing aids, which could negatively affect the resident's communication with staff and impact her quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe professional standards of nursing practice for one of 16 sampled residents (Resident 25) when the use of hearing aids was not monitored as directed by the physician. This failure had the potential to affect Resident 25's ability to communicate with staff and negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of 16 sampled residents (Resident 36 and Resident 462) who were dependent on staff for maintaining activities of daily living (ADLs, activities done every day such as eating, personal hygiene, bathing, dressing, and toileting), received the necessary services to maintain good nail care. These failures had the potential to negatively impact Resident 36's psychosocial well-being and had the potential for Resident 36 and Resident 462 to acquire self-inflicted skin injuries due to long fingernails.