Farmington Wellness & Rehabilitation

Inspectors wroteBased on observation and interview, the facility failed to promote care with dignity and respect for 16 residents observed during a random dining observation when the facility did not serve breakfast at the same time to all the residents seated at the same dining table. This deficient practice could likely result in residents feeling frustrated and disappointed.

Inspectors wroteBased on record review and interview, the facility failed to create accurate baseline care plans (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #7, R #18, R #38, and R #39) of 7 (R #3, R #5, R #6, R #7, R #18, R #38, and R #39) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care upon admission and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis 2 (R #3 and R #18) of 5 (R #3, R#5, R #6, R #18, and R #40) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food under sanitary conditions when staff:1. Prepared food and plated the food without wearing a beard restraint.2. Got ice from the ice machine without wearing a hair restraint.3. Failed to sanitize hands while consistently touching the apron he was wearing while plating the food.4. Plated the food while the paper meal ticket was on the plate. This deficient practice is likely to affect all 32 residents listed on the resident census list provided by the Administrator on 05/04/26 and is likely lead to foodborne illnesses in residents if food is not being stored properly. A. On 05/05/26 at 11:08 am, an interview and observation of the kitchen revealed the following:1. The cook was not wearing a beard restraint while cooking and plating food.2. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1(R #56) of 2 (R #6 and R #56) when staff failed to: 1. Ensure proper Personal Protective Equipment (PPE) was worn during wound care.2. Ensure proper hand hygiene practices are followed during wound care. 3. Ensure good infection control practices when staff wiped hands on pants during wound care. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness.

Inspectors wroteBased on record review and interview, the facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) to 1 (R #20) of 3 (R #20, R #60, and R #61) residents reviewed for beneficiary notices. If residents or their representatives are not provided with the beneficiary notices, then they may not make an informed decision about the services provided to them and could likely result in a decline in health and function.

Inspectors wroteBased on observation and interviews, the facility failed to safeguard resident's medical record information for 1 (R #59) of 3 (R #3, R #15, and R #59) residents reviewed for privacy and confidentiality of records when the staff left Private Health Information (PHI) in plain view on a computer screen, where unauthorized people had ability to access it. This deficient practice could likely lead to residents feeling embarrassed and ashamed.

Inspectors wroteBased on record review and interview, the facility failed to develop an accurate, comprehensive care plan within seven days of the completion of the comprehensive assessment for 1 (R #39) of 3 (R #3, R #5, and R #39) residents reviewed for care plans. This deficient practice could likely result in residents not getting the most appropriate interventions and treatments needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #7) of 3 (R #3, R #15, and R #40) residents reviewed for nutrition and weight management when the facility failed to:1. Assist R #7 with her meal as required.2. Notify the physician of R #7's 12.5% (percent) weight loss. These deficient practices could likely lead to residents suffering from malnutrition which could exacerbate (make worse) other medical conditions.

Inspectors wroteBased on observations and interviews, the facility failed to properly store medical supplies and medications when staff failed to ensure:Ensure the medication and supply room was locked and secured,Failed to dispose of expired blood collection tubes. These deficient practices are likely to affect all 32 residents residing in the facility according to the census provided by the Administrator on [DATE] and could result in resident having unauthorized access to medications, supplies and inaccurate lab results by using expired blood collection tubes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) for 1 (R #15) of 1 (R #15) residents reviewed during medication administration, when staff administered two out of 28 medications late, which resulted in a medication error rate of 7.14%. If medications are administered late, then residents are likely to experience less than optimal results from their medication regimen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure Nurses and Certified Medication Aids (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) vials and discarded them within 28 days of opening date for 1 (R #20) of 1 (R #20) resident reviewed. This deficient practice is likely to result in R #20 receiving medications that are less effective or expired in the facility.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to: 1. Ensure all medications were kept in their original packaging. 2. Ensure all expired supplies were not kept with unexpired supplies. 3. Document daily medication refrigerator/ freezer/ medication room temps. These deficient practices are likely to result in all 22 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication or improperly temperature-controlled medication that may have lost their potency or effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Discard opened, refrigerated food when it met its seven day shelf life or appeared to be decomposed; 2. Date food with received dates and use by dates, as required by Food and Drug Administration (FDA) Food Code and facility policy. These deficient practices are likely to affect all 22 residents listed on the census provided by the Director of Nursing (DON) on 12/04/23. These deficient practices could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observation, record review, and interview, the facility failed to properly date oxygen tubing and place the facemask in a plastic bag when not in use for 2 (R #120 and R #123) of 2 (R #120 and R #123) residents reviewed for respiratory care by not properly dating the oxygen tubing and not placing the facemask in a plastic bag when not in use. These deficient practices could likely lead to respiratory infections by the oxygen tubing becoming clogged due to condensation (process where water vapor becomes liquid) or becoming dirty leading to reduced flow of oxygen.

Inspectors wroteBased on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #125) of 1 (R #125) residents who were reviewed for documentation when they failed to accurately document: 1. A resident came out the straps used to keep her wheelchair in place when being transported. 2. Assessments staff completed on that day. 3. A physician was informed. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents.