Life Care Center of Farmington

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from unnecessary medications, in accordance with professional standards of practice, for 1 (R #1) of 1 (R #1) resident, when: A medication consent form was not completed as required before administration of a psychotropic medication (medication used to treat mental health conditions). A psychotropic medication gradual dose reduction (GDR; tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose) was not attempted or supported by documentation indicating a clinically contraindicated reason likely to impair function or cause psychiatric instability in the resident. This deficient practice is likely to result in residents being administered psychotropic medications that are unnecessary resulting in possible sedation and other unwanted side effects.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident, when staff failed to follow the physician orders for placement of R #1's urinary catheter (a thin, flexible tube which drains urine from the bladder) collection bag (also called a drainage bag; a device connected to the catheter tubing and collects urine). This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interview, the facility failed to provide the required transfer information to the residents' and the residents' representatives for 1 (R #3) of 3 (R #1, #2 and #3) residents, when staff failed to: Notify R #3 and/or R #3's representative in writing, and in a language and manner they understand, of the resident's transfer to the hospital. Send a written copy of R #3's transfer notice to the State Long Term Care Ombudsman (a government advocate for residents of long-term care facilities, such as nursing homes and assisted living facilities, working to protect their rights and improve the quality of care they receive) before or after R #3's hospitalization. [...]

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident representative of a medication change for 1 (R #2) of 1 (R #2) residents reviewed, when:R #2's Parkinson's (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination) medication management was altered and the facility failed to notify R #2's representative of the medication change per R #2's care plan. Failure to notify the resident representative of a medication change is likely to result in delayed awareness of the change and may contribute to delayed or inadequate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered and secured medications for all 112 residents listed on the facility census when: Medication carts were not secured and left unattended during medication pass. Medications were pre-poured (the practice of preparing and storing medications in advance of their scheduled administration) and left unattended without supervision. These deficient practices increased the risk of unauthorized access, medication diversion, contamination, and administration of medications to the wrong resident. Failure to ensure facility nursing staff do not pre-pour medications, do not leave medications unattended, and consistently secure medication carts is likely to create a substantial likelihood that residents, staff members, and/or visitors could access or remove medications that were not prescribed to them.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective Infection Prevention and Control Program during a COVID-19 (a viral respiratory disease) outbreak affecting all 58 residents residing on Unit A, when: The facility failed to exclude symptomatic staff from resident contact. The facility did not effectively identify and control the spread of infection. The facility failed to prevent unit-wide clustered transmission consistent with uncontrolled spread. This deficient practice like resulted in residents acquiring COVID-19 infections with prolonged isolation precautions.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) was accurate for 1 (R #3) of 1 (R #3) resident reviewed for PASARR accuracy when the facility did not properly screen for mental disorders or intellectual disabilities prior to admission. This deficient practice is likely to result in the facility not providing the specialized services and support needed by residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure 1 (R #3) of 1 (R #3) residents reviewed received the appropriate pharmacy services when: R #3 did not receive prescribed medications as ordered. A follow-up and coordination with the pharmacy and prescribing providers was completed when R #3's ordered medications were unavailable. The facility did not obtain nor administer the complete provider-ordered taper of Venlafaxine (antidepressant) during a cross-taper process (a process used when switching antidepressants. It involves gradually reducing the dose of one antidepressant while simultaneously increasing the dose of another) resulting in an unintended interruption of therapy. This deficient practice is likely to place residents at risk for withdrawal symptoms, worsening mental health symptoms, and delayed treatment.

Inspectors wroteBased on record review and interview, the facility failed to promote resident choices for 1 (R #2) of 1 (R #2) resident reviewed for choices, when an outside individual entered the resident's room and removed a religious item without obtaining authorization from the resident's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care). If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide access to medical records for 1 (R #3) of 1 (R #3) resident reviewed for access to medical records. If the facility fails to provide residents with access to their medical records upon request, then residents' rights to review, obtain, and understand their own health information is compromised. This deficient practice is likely to result in delays involving care, lack of informed decision-making, and unnecessary barriers to exercising their rights.

Inspectors wroteBased on record review and interviews, the facility failed to notify the Medical Director (MD) of missed antidepressant doses for 1 (R #3) of 1(R #3) resident reviewed for medications when: The facility did not administer medications according to the prescribed schedule, including not following proper tapering protocols for an antidepressant medication. The facility failed to provide timely (immediate) communication with the Medical Director. These deficient practices are likely to result in untreated or worsening depression, delayed treatment, and adverse reactions for the residents.

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to store food under sanitary conditions when staff failed to ensure: 1. Food items were labeled, dated, and protected in the kitchen dry storage and refrigerator. 2. The kitchen was clean and free of stains, spatters, and food debris. 3. Single use items were covered and protected. 4. Staff wore hairnets and beard guards while working in the kitchen. 5. The ice machine drained through an air gap. These deficient practices are likely to affect all 110 residents listed on the resident census list provided by the Administrator on 05/12/25. These failures are likely to lead to foodborne illnesses in residents if food is not stored properly and if staff do not adhere to safe food handling practices.

Inspectors wroteBased on record review and interview, the facility failed to provide care that met professional standards for 1 (R #105) of 1 (R #105) resident when the facility failed to obtain and administer carvedilol (used to treat high blood pressure and certain heart conditions) as ordered by the physician. This deficient practice could likely result in a resident having an adverse reaction due to not receiving medications as ordered.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the facility was free of the potential for accidents and hazards for residents in B unit, when staff failed to ensure the following: 1. The Emergency Cart (E-cart, a mobile unit that contains essential supplies, and equipment needed to respond to life-threatening emergencies in hospitals and other medical facilities) was locked to prevent access to scissors and other medical supplies. 2. Shower room was locked to prevent access to shaving razors and hazardous cleaning materials. These deficient practices are likely to affect all the 37 residents in B Unit listed on the resident census list provided by the Administrator on 05/12/25 and are likely to lead to residents experiencing avoidable accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 3 (R #44, R #45, and an unidentified R) of 3 (R #44, R #45, and an unidentified R) residents reviewed. This deficient practice is likely to result in all 3 residents receiving medications that are less effective or expired in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #14) of 1 (R #14) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 (R #105) of 1 (R #105) resident reviewed for care plans. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 1 (R #57) of 3 (R #16, #41 and #57) residents when staff failed to ensure R #57 received showers timely. This deficient practice could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed, and undignified.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident wore her oxygen, and the oxygen ran continuously for 1 (R #105) of 1 (R #105) resident reviewed for oxygen. If the facility is not following orders for oxygen use then the resident may be low on oxygen, which had the potential to cause health concerns such as headache, difficulty breathing or rapid heart rate.

Inspectors wroteBased on observation and interview, the facility failed to identify quality deficiencies through their Quality Assurance and Performance Improvement Plan (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients) when staff were unaware the exit doors in the Memory Unit did not function as they were supposed to when the fire alarm was activated. This deficient practice is likely to affect all 118 residents, per census list provided by the Administrator (ADM) on 05/12/25. This deficient practice could likely result in staff and residents not able to safely evacuate the facility in case of emergency.

Inspectors wroteBased on record review and interview, the facility failed to notify the family member/Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) for 1 (R #1) of 3 (R #1, #2, and #3) residents when changes in R #1's medication were made. If the facility is not notifying the resident's POA when the resident has a change in medication, then the POA is unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nursing staff had the competencies required to ensure 2 (R #1 and R #12) out of 2 (R #1 and R #12) residents received care that met the health and safety needs of the residents when staff failed to: - Prevent R #12 from rolling off the bed, causing a serious head injury that resulted in death. - Position R #1's catheter leg bag (a bag that is attached to the leg and catches urine) below his catheter (tube placed in the bladder to drain urine from the bladder) while he was in bed, which could cause urine to back up into the bladder and cause an infection. - Properly assist R #1 with standing, which caused him pain.

Inspectors wroteBased on record review and interview the facility failed to prevent an accident when staff did not provide appropriate care for 1 (R #12) out of 1 (R #12) resident looked at for accidents. This deficient practice caused R #12 to fall out of bed, hitting her head, and passing away at the hospital hours later.

Inspectors wroteBased on record review and interview the facility failed to thoroughly assess the pain level of 2 (R #1 and #11) of 2 (R #1 and #11) residents looked at for an injury of unknown origin and pain, when staff: 1. Pulled on R #1's arm to assist him to get out of bed after complained of pain in his arm. 2. Allowed R #11 to sit in severe pain for several hours before the physician saw the resident and sent her to the emergency room for x-rays.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when staff failed to remove a leg catheter bag for 1 (R #1) out of 1 (R #1) resident while he lay in bed. This deficient practice of not adhering to an infection control program could likely cause a urinary tract infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 3 (R #1, #20 and #21) of 3 (R #1, #20 and #21) residents observed during dining. This deficient practice could likely create a feeling of frustration, embarrassment, and disappointment.

Inspectors wroteBased on interview, the facility failed to investigate an injury of unknown origin for 1 (R #11) out of 3 (R #1, #11 and #12) residents reviewed for reporting to the State Agency. The deficient practice could cause residents to go without treatment and may expose them to injuries.

Inspectors wroteBased on record review and interview, the facility failed to report unwitnessed falls resulting in injury (an indicator of possible neglect or abuse) to the State Survey Agency, for 2 (R #7 and R #10) of 3 (R #7, R #8, and R #10) residents reviewed for falls. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents and unable to assure residents have a safe and hazard free environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive, person-centered care plans which included information about current fall prevention strategies being used for 2 (R #7 & R #10) of 3 (R #7, R #8, and R #10) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the care needed to reach their highest practicable level of well-being.

Inspectors wroteBased on observations and interviews the facility failed to: 1. Ensure all medication carts were locked when not in use. This deficient practice is likely to affect all 35 residents in A hall, identified on the census list provided by the Executive Director (ED) on 2/28/24, by allowing unauthorized persons access to their medications and personal health information.

Inspectors wroteBased on observation and interview, the facility failed to discard food after it reached its shelf life or after it expired. This failure was likely to affect all 106 residents listed on the census provided by the Director of Nursing (DON) on 01/29/24. This deficient practice could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being discarded timely.

Inspectors wroteBased on observations and interviews the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies in the medication room. These deficient practices are likely to result in all 82 residents residing in halls 100, 300, and 600, as identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication and having expired medical supplies used in their treatments.

Inspectors wroteBased on record review and interview, the facility failed to include information about a medication used to treat depression for 1 (R #102) of 3 (R #81, R #102, and R #259) residents reviewed for comprehensive care plans. This deficient practice could likely result in residents not receiving the follow-up care that is needed when being treated with an antidepressant medication. A. Record review of R #102's face sheet revealed R #102 was admitted to the facility on [DATE] with the diagnosis of depression, unspecified. B. Record review of R #102's current physician orders revealed an order, dated 12/21/23, for escitalopram oxalate (a type of antidepressant), 10 milligrams (mg). C. Record review of R #102's care plan, last revised 12/29/23, revealed R #102 received an antidepressant medication; however, the care plan did not include the side-effects of the antidepressant medication. D. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical record was accurate and reflected resident care for 1 (R #39) of 1 (R #39) resident reviewed for wounds. This deficient practice could likely result in staff confusion as to the services and treatment provided.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (R #51) out of 5 (R #'s 16, 43, 51, 64, and 92) residents reviewed were offered vaccinations in a timely manner. This deficient practice is likely to put residents at risk for developing illness or infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and family members were fully aware of the next steps needed for their continuation of care upon discharge from the facility for 2 (R #3, and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for a safe discharge process. This deficient practice could likely result in residents not receiving the care they need to continue to heal and to prevent avoidable acute care admissions. A. Record review of the facility's policy Discharge Summary, last reviewed 08/10/23, revealed the post-discharge plan of care must indicate where the individual planned to reside, any arrangements made for the resident's follow-up care, and any post-discharge medical and non-medical services. Findings for R #3 B. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to meet professional standards for nursing care for 3 (R #'s 6, 60 and 76) of 12 (R #'s 6, 10, 13, 15, 22, 36, 60, 75, 76, 85, 89, and 93) residents reviewed for proper administration techniques when medications given to them, by: 1. Failing to administer eye drops to R #6 with techniques that are designed to ensure absorption in the eyes of correct dose, 2. Failing to educate residents on proper use of their prescribed respiratory inhalation medication devices, prior to administration, resulting in R #'s 60 and 76 likely not receiving the prescribed amounts of medication, and 3. [...]

Inspectors wroteBased on record review and interview the facility failed to provide restorative services (measures provided by nursing staff and directed toward re-establishing and maintaining the residents' fullest potential) needed for 1 (R #44) of 1 (R #44) resident reviewed for restorative services. This deficient practice could result in any resident in need of restorative care to experience a decline in their ability to move in bed, transfer safely, walk, eat, and perform grooming or other activities of daily living (ADLs).

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure residents maintain personal grooming for 5 (R #4, R #26, R #57, R #87 and R #91) of 8 (R #4, R #8, R #26, R #31, R #57, R #72, R #87 and R #91) residents reviewed for facial and nail grooming Activities of Daily Living (ADLs). These deficient practices could likely affect the residents' sense of dignity, resulting in feelings of shame or embarrassment, and could likely affect the health of the residents, causing infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 (R #6 and 18) of 3 (R #4, 6 and 18) residents reviewed for wound care. Failure to provide wound care as ordered by the physician could likely cause residents to have worsening wounds that could become infected causing delayed healing.

Inspectors wroteBased on record review and interview, the facility failed to assess for the benefit versus potential risk of increasing a dose of an antipsychotic medication (an reduce or relieve symptoms of psychosis, such as delusions (false beliefs) and hallucinations) after R #18 complained about not receiving wound care for 1 resident (R #18) of 5 (R #8, 18, 36, 54 and 91) reviewed for unnecessary medications. This deficient practice could likely cause residents to receive medications they do not need or may experience an adverse side effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% by performing 5 medication errors out of 43 opportunities for 5 (R #'s 13, 15, 22, 60, 76,) of 12 (R #'s 6, 10, 13, 15, 22, 36, 60, 75, 76, 85, 89, and 93) residents reviewed during medication administration. This resulted in a medication error rate of 11.43%. If medications are administered without regard to manufacturer's instructions for administration or specific alternate instructions from a knowledgeable professional [such as a pharmacist], residents may likely not experience the maximum benefit intended and fail to achieve their highest level of well being.

Inspectors wroteBased on interview and record review, the facility failed to notify and get consent from the Power of Attorney (POA) for R #18 for an antipsychotic medication increase for 1 (R #18) of 1 (R #18) residents reviewed for unnecessary medication. This deficient practice could likely cause residents to receive unwanted and unnecessary medications by not notifying the resident or the residents POA, and allowing them to decide if the medication was wanted or not.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that the care plan was comprehensive and covered all care needs for 1 (R #18) of 1 (R #18) residents reviewed for wound care. If the facility fails to capture care needs this could likely put the resident at risk of not receiving the care and services they need.

Inspectors wroteBased on record review and interview, the facility failed to have physician orders for 1 (R #54) of 1 (R #54) resident by administering oxygen without a physician's order. If the facility fails to obtain orders for the administering of oxygen, it could likely cause the resident to not receive the therapeutic benefits, resulting in possible harm to the resident.