Fairview Nursing and Rehabilitation Community

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice related to monitoring laboratory results for one resident (R101) of 3 residents reviewed for professional standards and quality of care, resulting in a delay of treatment for a bacterial infection, the potential for a diminished medical outcome, and the resident not maintaining or achieving their highest practical physical well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1). Maintain infection control practices, specifically the use of gloves during administration of insulin injections, 2). Sanitize or clean resident shared equipment specifically a glucometer (a portable device used to measure the concentration of glucose in the blood) for 6 (Resident #25, Resident #17, Resident #7, Resident #30, Resident #28, and Resident #22) of 6 residents reviewed for glucose monitoring during medication administration; and 3). Properly use personal protective equipment (PPE) for a resident in enhanced barrier precautions during a transfer for 1 (Resident #53) of 3 residents reviewed for transfers, resulting in the potential for the spread of infection, cross contamination, and disease transmission.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 1 resident (Resident #6) of 5 residents reviewed for medications, resulting in the lack of physician notification of elevated blood sugar levels per physician's order, and the potential for worsening of the medical condition.

Inspectors wroteThis citation pertains to Intake #1323219. Based on interview and record review, the facility failed to ensure incontinence care was received timely, with the appropriate number of staff assistance, and that it was documented for 1 resident (Resident #10) of 3 residents reviewed for ADL (Activities of Daily Living) care resulting in dissatisfaction with care, potential for skin breakdown and injury to occur.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that an assistive transfer device (gait belt) was used during a transfer for 1 (Resident #53) of 3 residents reviewed for proper transfers resulting in the potential for a fall and/or an injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper label and dating of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the main kitchen on 8/06/2024 at 9:26 AM, the reach in refrigerator was observed to have the following: 1 lemonade pitcher had a prepare date of 8/1/2024 and a use by date of 8/3/2024. 1 plastic storage container of individual cups of mayonnaise with no label and date. 1 plastic storage container of individual cups of mustard with no label and date. 1 plastic storage container of individual cups of tartar sauce with no label and date. 1 shallow pan with individual bread slices in individual ziploc bags with no label and date. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment after a change in health status, in 1 of 13 residents (Resident #40) reviewed for a significant change in condition, resulting in the potential for unassessed physical, mental, emotional, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly implement enhanced barrier precautions for 1 (Resident #11) of 13 residents sampled for infection control, resulting in the potential for cross contamination and spread of infection.

Inspectors wroteThis citation pertains to intake #MI00142077 Based on interview and record review the facility failed to provide an environment free from abuse in 1 resident (Resident #101) of 3 residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake #MI00142077 Based on interview and record review the facility failed to implement their abuse prevention policy in 1 resident (Resident #101) of 3 resident reviewed for abuse, resulting in the potential for abuse to go unreported and for abuse to continue.

Inspectors wroteThis citation pertains to intake MI00140159. Based on observation, interview and record review, the facility failed to maintain continuity of care according to professional standards following a change of condition related to a toe injury for 1 of 3 residents (R102) reviewed for quality of care, resulting in lack of communication, delay in assessment, treatment, and inaccurate documentation, that resulted in osteomyelitis and amputation of toes.

Inspectors wroteThis citation pertains to intake # MI00138591 Based on observation, interview and record review, the facility failed to ensure all caregivers and staff received education on dementia care to prevent staff to resident physical and verbal abuse for 1 (Resident #21) of 19 residents reviewed for dementia care, resulting in an Immediate Jeopardy when on 8/1/23 Resident #21 who was known to have dementia behaviors and required 2 person physical assistance due to the behaviors, was sworn at, suffered bruising around his neck, and received a skin tear while receiving cares from an agency employed staff member who had not received training on caring for residents with dementia.

Inspectors wroteThis citation is linked to intake # MI00138591 This citation contains 2 Deficiency Practice Statements, DPS #1 and #2. DPS #1 Based on observations/interviews/record review, the facility failed to protect the resident's right to be free from staff to resident verbal and physical abuse for 1 (Resident #21) of 19 residents reviewed for abuse, resulting in Resident #21 sustaining a reddened and bruised area extended across the front of his neck and a bandaged wound was present on his upper torso.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the care plan for a resident who had known dementia behaviors and required 2-person physical assistance, in 1 (Resident #21) of 19 residents reviewing for care planning, resulting in Resident #21 receiving physical injury and psychosocial harm during cares.

Inspectors wroteThis citation pertains to intake # MI00138591 Based on observations, interview, and record review the facility failed to provide in depth Dementia Care training to all current, newly hired and agency employed staff resulting in an incident of staff to resident abuse for Resident #21, with a potential for a decline in physical, mental, and psychosocial well- being and unmet care needs for all residents with dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a dietary manager with appropriate training and certifications to provide oversight of kitchen and clinical nutritional services resulting in the potential to result in food service sanitation failures, food borne illness, among all 41 vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Properly date and discard food products, 2. Maintain cleanliness of food and non-food contact surfaces, and 3. Consistently monitor temperatures of the walk-in refrigerator, resulting in the potential of an increased risk of contaminated foods and food borne illnesses that could affect the vulnerable population of 41 residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented per the standard of practice 1.) during a wound dressing change for 1 resident (R392) of 2 residents reviewed for wound dressing changes, 2.) in an resident common area, and 3.) for the use of personal protective equipment (PPE) during laundry services, resulting in the potential for the spread of infection, cross-contamination, and disease transmission.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff, including contractual staff were trained in the facility expectations on caring for residents in the facility which inclueded training in communication, resident rights, abuse, neglect, and exploitation, quality assurance, infection control, and ethic training, resulting in the potential for decreased resident safety.

Inspectors wroteBased on interview and record review, the facility failed to allow resident room visitations for 3 of 3 residents (R4, R37, and R26), reviewed for resident choice resulting in visitation privileges inconsistent with resident preferences and potential for increased social isolation, depression, and anxiety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff was adequately trained and evaluated for competencies specifically related to licensed nurses administering intravenous (IV) medications in 2 of 2 Residents (Resident #9 and Resident #37) observed for IV medication administration, resulting in the potential for ineffective medication therapy, complications, and adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual performance evaluations for 3 certified nursing assistants (CNA #RR, CNA #QQ, and CNA U) out of 3 reviewed for annual performance evaluations, resulting in the potential for the delivery of nursing and related services that does not support or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate less than 5% (total error rate of 8%) in 2 of 6 sampled residents (Resident #10 and Resident #35) reviewed for medication administration, resulting in the potential for reduced medication effectiveness and increased risk of adverse reaction and/or side effects.