Fairview Haven

Inspectors wroteBased on observation, interview and record review the facility failed to monitor medication room freezer temperatures and failed to store medications separately from food. This failure affects all 47 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions for one of three residents (R27) reviewed for falls in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate Enhanced Barrier Precautions for one (R14) of sixteen residents reviewed for infection control in a sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of unused medications from unknown residents. This failure has the potential to affect all 46 residents residing in the facility reviewed for medication disposal in the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent injury during care transfers for a resident requiring total assist and protective sleeves to both arms. This failure affects one (R12) of three residents reviewed for transfers from a total sample list of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a self administration of medication assessment for residents with medications at bedside for two of two residents (R4, R29) reviewed for self administration of medications on the sample list of 18. Findings Include: The facility's undated Self Administration of Medication Policy documents residents in our facility who wish to self administer their medications may do so if it is determined that they are capable of doing so. The staff and practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self administering medications and document their findings and the choices of the residents who are potentially capable of self administering medications. [...]

Inspectors wroteBased on interview and record review the facility failed to complete residents initial assessment for an antidepressant and failed to complete quarterly assessments for antidepressants and an antipsychotic medication. This failure affects one of five residents (R22) reviewed for unnecessary medications in the sample list of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment and utensils in a safe, clean, sanitary condition to prevent the potential for cross-contamination of food from physical contaminants. These failures have the potential to affect all 47 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN (as needed) medications were not ordered for more than 14 days maximum duration permitted for PRN medications without justification, failed to complete a psychotropic medication assessment prior to starting a psychotropic medication, and failed to care plan non-pharmacological interventions to assist with behavior management for three of five residents (R27, R30, and R36) reviewed for psychotropic medications on the sample list of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained by administering an injection in the dining room for one of six residents (R35) reviewed for medication administration on the sample list of 25. Findings Include: On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's ordered insulin injections and entered the dining room to administer it. R35 was sitting at the dining room table with R44 when V7 stated V7 needed to administer R35's insulin. R35 lifted R35's shirt to make R35's abdomen accessible to V7, and V7 administered the two insulin injections. On 6/22/22 at 8:44 am, R35 stated, staff normally don't give R35 insulin in the dining room but instead make R35 go to R35's room to get it. On 6/22/22 at 1:38 pm, V1 Administrator stated the facility does not have a policy for dignity. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for anticoagulant therapy for one of 13 residents (R19) reviewed for care plans in the sample list of 25.

Inspectors wroteBased on record review, observation, and interview, the facility failed to keep a resident's oxygen tubing off the floor and failed to label portable oxygen tubing according to facility policy. This failure affects two of three residents (R14 and R16) reviewed for respiratory care on the sample list of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Manufacturers Recommendations and facility policy for one (R35) of six residents reviewed for medication administration in the sample list of 25. The facility had 2 errors out of 33 opportunities for a medication error rate of 6.06%. Findings Include: R35's June 2022 POS (Physician Order Sheet) documents orders for Lantus {Long Acting Insulin} 10 units SQ (Subcutaneously) every morning and Novolog {Rapid Acting Insulin} 100 units /ml per sliding scale coverage SQ before meals and at bedtime{based on blood glucose level}: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications are labeled appropriately for one of six residents (R35) reviewed for medication labeling in the sample list of 25. Findings Include: The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date. On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's morning medications which included insulin's: Novolog {Rapid Acting Insulin} and Lantus {Fast Acting Insulin}. V7 pulled the unlabeled Novolog and Lantus from a bag in the medication cart that had a worn pharmacy label on it. [...]