Pierpont Center at Fairmont Campus

Inspectors wroteBased on record review, and staff interview the facility failed to ensure residents Minimum Data Set (MDS) assessment correctly reflected Resident #38's physical status. This failed practice was a random opportunity for discovery and had the potential to effect a limited amount of residents during the complaint survey. Resident identifier #38. Facility Census 108. Findings Include:a) Resident #38A record review on 02/17/26 at 1:30 PM revealed a current Activities of Daily Living care plan for Resident #38 that read as follows:Focus:Resident/patient requires assistant/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility. Goal:Resident/patients ADL care needs will be anticipated and met throughout the next review period. Interventions include the following: [...]

Inspectors wroteBased on record review, staff interview, and family interview the facility failed to provide care and services in accordance with professional standards of practice, by not providing supervision of incapacitated residents at out of facility doctor appointments. This failed practice was found true for (1) one of (3) three residents reviewed for doctor appointments during the complaint survey. Resident identifier #38. Facility Census 108.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to thoroughly investigate reportable incidents and report the results of those investigations to the State Agency within five (5) working days of the incident and if the alleged violation was verified to include the appropriate corrective action taken. Resident identifiers: #70, #71, #73, and #121. Facility census: 111. a) A facility reported incident dated 04/13/25 involving Resident #70 and a facility reported incident dated 06/06/25 involving Resident #71 were reviewed having a Five (5) Day Follow-up Investigation Report submitted to the state agency. The facility's documentation was reviewed and the Five (5) Day Follow-up forms for each incident were in the facility's file with no proof of submission to the state agency. [...]

Inspectors wroteBased on observation, record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to activities, fall interventions, and Advance Directives (AD). This failed practice was found true for (3) three of 31 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #5, #52, and #24. Facility census 111. c) Resident #24 On 01/05/2026, Resident #24 care plan was reviewed for the resident's Advanced Directive wishes. The resident's Advanced Directives were not care planned. The resident's care plan was confirmed by the Corporate Compliance Advisor.

Inspectors wroteBased on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizingtemperature. This failed practice was true for (1) of one (1) hallways tested for food tray temperatures throughout the Long-Term CareSurvey Process. Resident identifiers: #24 and #112. Facility census: 111. Findings Included: a) During an observation on 01/06/26 at 1:25 PM of the 220 hall meals being passed with only 2 staff members delivering all trays to residents on that hall. The District dietary manager took the temperature of the food, at time of service. Temperature of the food was as follows: French Fries 110 degrees Fahrenheit. Hamburger patty 113 degrees Fahrenheit. District Dietary Manager confirmed that the food was not served at 120 Degrees Fahrenheit at time of service. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect multiple residents of the facility. Facility census: 111. Findings Included:On 01/05/26 at 11:45 AM, during Initial Brief Tour of Kitchen, with The Kitchen Dietary Manager, who acknowledged the kitchen the following observations:a) The kitchen refrigerator inside temperature was at 45 degrees verified via inside thermometer. [...]

Inspectors wroteBased on observation and staff interview the facility failed to store garbage and refuse in a proper manner. Two (2) of three 3 (three) dumpsters were over filled and the lids were not closed. This had the potential to affect more than an isolated number of residents that resided in the facility. Facility census: 111. Findings Included:a) On 01/07/26 at 2:50PM, during initial observation of the dumpsters, with the Corporate Interim Administrator (CIA), the following was observed:A dumpster located on the front side of the facility was overfilled with the inability to completely close the lid. In the rear of the facility where 2 (two) dumpsters were located, the left one was observed to be overfull with the inability to completely close the lid. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical records related for a Physician's Order of Treatment (POST) form and a resident's diet order. These failed practices had the potential to affect more than a limited number of residents. Resident identifier: #24 and #126. Facility Census: 111.

Inspectors wroteBased on observation, policy review, record review and staff interview the facility failed to maintain an infection control program, designed to help prevent the spread of disease. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #52, #86, and #97. Facility census 111. Findings Include: a) Resident #52 An observation on 01/06/2026 at 12:40 PM, revealed a Droplet precautions sign on Resident #52's door that read as follows: Special Contact and Droplet Precautions Instructions for entering the room are as follows: * Perform hand hygiene before and after patient contact, contact with environment and after removal of Personal Protective Equipment (PPE). * Wear an N95 respirator, gown, face shield and gloves upon entering the room. * Keep room door closed. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to keep needed items in reach of residents and provide necessary assistance to help maintain residents independence by not keeping call lights in reach of residents. This failed practice was a random opportunity for discovery and affected a limited number of residents during the Long-Term Care Survey Process. Resident identifiers: #51, and #72. Facility Census: 111. Findings Include:a) Resident #51The initial observation on 01/05/26 at 12:15 PM, revealed Resident #51 lying in bed repeatedly saying, I hurt, I hurt. Resident #51's call light was lying behind her bed. During an observation and interview, on 01/05/26 at 12:25 PM, Licensed Social Worker (LSW) #56, confirmed that Resident #51's call light was not in reach and that she felt like she could use the call light. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide bed hold notification for residents being discharged /transferred. This is true for two (2) of two (2) resident's reviewed for discharge/transfer. Resident identifiers, Resident #117 and Resident #115. Facility Census 111.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of three (3) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #1. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a baseline care plan was developed and implemented with instructions needed to provide effective and person-centered quality care. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #126. Facility Census:

Inspectors wroteBased on record review, interview and observation the facility failed to ensure a resident's care plan was revised in the areas of dialysis catheter and activities. Resident identifiers: #15 and #51. Facility Census: 111Findings included:a) Resident #15 On 01/07/26 a review of Resident #15's care plan revealed the following: Resident is scheduled for outpatient surgery on 10/21/25 to get dialysis catheter removed. Date initiated and created 10/19/25. Goals and interventions were also listed for time of procedure. On 01/07/26 2:38 PM, Resident #15 reported he had a dialysis catheter removed from his chest a few moths ago, around October and now has a fistula in his arm. He pulled down his shirt without being prompted and exposed the cite where his catheter once was and stated it had healed and that there were no issues. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to provide a program of activities to meet the interest of and support the physical, mental, and psychosocial well-being of each residents. This failed practice was found true for (2) two of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #51, and #52. Facility Census 111. Findings Include: a) Resident #51 The initial observation on 01/05/26 at 1:59 PM, revealed Resident #51 lying in her bed, saying repeatedly, I hurt, I hurt. There was no stimulation in the room. Further observation on 01/06/26 at 2:00 PM, revealed Resident #51 lying in her bed, turned toward the separation curtain. No stimulation on in the room. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure the environment in which it had control of to be as free from accident hazards as possible, by not ensuring fall prevention interventions were being followed. This failed practice was found true for (1) one of (3) three residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #5. Facility census: 111. Findings Include: a) Resident #5 A record review, on 01/07/26 at 5:30 PM, revealed that from 10/01/25 to present, Resident #5 has had (6) six falls. One (1) fall with serious injury, and two (2) of the falls were from bed one causing a skin tear to her right eye. Further record review revealed a falls care plan that read as follows:Focus: Resident is at risk for falls: Impaired mobility. Fall on 08/30/25 no injuries. [...]

Inspectors wroteBased on record review, staff interview and resident interview, the facility failed to ensure staff supports the nutritional well-being of the residents while respecting the individual's right to make choices about their diet and taking the resident's preference into consideration. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #24 and #97. Facility Census: 111.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the facility assessment identified the staffing levels and training requirements needed to provide the necessary care and services for their residents. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 106.

Inspectors wroteBased on resident and staff interviews, the facility failed to ensure each resident had reasonable and ready access to their personal funds held by the facility. This was true for four (4) out of 11 residents that were interviewed during the resident council meeting. This had the potential to affect more than a limited number of residents. Facility census: 106.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the P-Tac (packaged terminal air conditioner) vents (filters on the heat and air conditioners that are in each room.); and leaving a large amount of transparent type on a resident wheelchair. Resident identifiers: #35, #90. The facility census 106.

Inspectors wroteBased on staff interview and record review the facility failed to ensure all residents were free from unnecessary medication psychotropic medications used for refusal of care. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106.

Inspectors wroteBased on record review and staff interview, the facility failed to update the Pre admission Screening and Resident Review (PASRR) for a resident that was diagnosed with a serious mental disorder upon admission to the facility. This was true for nine (9) of ten (10) residents reviewed for Preadmission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifiers: #82, #38, #6, #32, #29, #37, #102, #77. Facility census:106.

Inspectors wroteBased on record review and staff interview, the facility failed to provide information and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner and failed to follow a physician's order regarding Insulin. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Facility census 106.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure all vials of multi-use insulin were labeled with the initial date it was opened. This was true for three (3) out of three (3) vials found in the medication cart. Resident identifiers: #32, #72, and #71. Facility census 106.

Inspectors wroteBased on observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. It was discovered food was not stored properly in the freezer, a trash can was situated near the beverage dispensers, a broken floor tile and a dirty floor in the walk-in freezer. This had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 106.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies of which it did have or should have had knowledge. The discovery was made during the facility tasks area for a Safe/Clean/Comfortable and Homelike environment for leaks in the ceiling, damaged furniture, a resident's wheelchair had damage to the armrest and the heating, ventilation and air conditioning (HVAC) units had an excessive amount of dust buildup. These deficient practices did not allow for a safe, clean, comfortable and homelike environment for residents. Facility census: 106.

Inspectors wroteBased on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent cross-contamination and the development and transmission of communicable diseases and infections with regards to laundry services, bed pan storage and the community ice machine. This practice had the potential to affect all resident's resident in the Facility. Resident Identifiers: #16, #256, #257, and #59. Facility census: 106.

Inspectors wroteBased on observation, resident interview, record review and staff interview, the facility failed to ensure the residents choices were honored in regard to diet. This was true for one (1) of one (1) residents reviewed for choices. Resident identifier: #9. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's representative in a timely fashion when care was altered. An antibiotic, Amoxicillin, was ordered for Resident #54 on 03/08/24 but the Resident Representative was not informed of the new medication order. The facility's failure to notify the resident's representative of a change in condition was true for one (1) of 29 residents sampled in the Long-Term Care Survey Process. Resident Identifier: #54. Facility Census: 106.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a resident's right for privacy and confidentiality. Resident #95 had three (3) signs regarding personal care information posted throughout her room. Resident identifier: #95. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident fall resulting in serious bodily injury was reported in a timely manner to the appropriate state agencies. This failed practice was true for one (1) of two (2) residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #29. Facility Census: 106.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide the Notice of Transfer to the State Ombudsman. This was discovered for one (1) of one (1) residents reviewed for a transfer/discharge during the Long-term Care Survey Process. Resident #105 was transferred to another long-term care facility and no notice of transfer was sent to the State Ombudsman. Resident identifier #105. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to update the PASARR for a resident that had a diagnosis of a serious mental disorder after admission to the facility. This was true for one (1) of ten (10) residents reviewed for Pre admission Screening and Resident Review (PASARRs) during the long-term care survey process. Resident Identifier: #6. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the failed to develop a comprehensive person-centered care plan for the area of discharge planning. This was true for one (1) of one (1) resident care plans reviewed for discharge planning during the Long-Term Care Survey Process. The care plan for Resident #105 was not developed for discharge planning. Resident identifier: #105. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a person-centered comprehensive care plan. This was true for one (1) of four (4) resident care plans reviewed for urinary catheter care during the Long-Term Care Survey Process (LTCSP). The care plan for Resident #84 had not been revised when the urinary catheter was removed. Resident identifier: #84 Facility census: 106.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for one (1) of one (1) residents reviewed for ADL care during the long-term care survey process. Resident Identifier: #38. Facility census: 106.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment remained free of accident hazards over which it had control. A prescribed medication was found on the floor in Resident #43's room. This was a random opportunity for discovery. Resident Identifier: #43. Facility census: 106.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure all residents were free from unnecessary psychotropic medications used for refusal of care, no rationale provided for continuing to use a psychotropic PRN (take as needed) medication used longer than 14 days. This was true for two (2) out of five (5) reviewed for unnecessary medication. Resident identifiers: #5. and #91. Facility census 106.

Inspectors wroteBased on observation and staff interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This was a random opportunity for discovery. Resident identifier: #37. Facility census: 106. Findings Included: a) Resident #37 An observation on 03/11/24 at 12:36 PM, noon meal, found Resident #37 having issues drinking her milk. Review on 03/11/24 of Resident #37's tray card revealed regular water in a spout cup. During an interview on 03/11/24 at 12:40 PM, Nurse Aide #67 stated that Resident #37 doesn't like the spout cup, so they don't provide it to her. A record review on 03/12/24 at 9:12 AM revealed a care plan: Focus: - Resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: [...]

Inspectors wroteBased on record review and resident and staff interview, the facility failed to maintain accurate and complete medical records by failing to accurately record side effects of psychotropic medications, and not accurately documenting the type of ADL care provided to dependent residents. This was true for two (2) of two (2) residents reviewed for documentation during the long-term care survey process. Resident identifiers: #38, #91. Facility census: 106.

Inspectors wroteBased on observations, family interview, and staff interviews the facility failed to provide a homelike environment by not having adequate bed linens. This had the potential to affect all residents residing on the A hallway. Resident identifier: Resident #3. Facility Census: 108.

Inspectors wroteBased on observation and staff interview the facility failed to post up-to-date data for nurse staffing. During the tour for a complaint investigation, it was discovered the Daily Nurse Staffing Form had not been updated since 09/01/23. The deficient practice had the potential to affect more than a limited number residents and visitors. Facility census: 108.

Inspectors wrote, Based on observation and staff interview, the facility failed to provide a dignified dining experience. This was true for six (6) out of 12 residents dining in the Vintage dining room. Facility census 112.

Inspectors wroteBased on observation, resident council minutes, resident interview, and staff interview the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances concerning issues of resident care. This had the potential to affect more than a limited number of residents living in the facility. Facility census: 112. Findings Included: A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Policy .Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative a) Resident Council Meeting held on 05/30/22 Record review on 11/29/22 revealed a Resident Council meeting held on 05/30/22. The following concerns were voiced: [...]

Inspectors wroteBased on record review, staff interview, and resident interviews, the facility failed to notify a resident and/or resident's responsible party of a significant change in the resident's condition. Resident's #64 and #42 was not informed of physician appointments and Resident #105's representative was not notified when a change occurred in the medication regimen. This deficient practice was found for three (3) of 17 sampled residents. Resident identifiers: #64, #42 and #105. Facility census: 112.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to have adequate clean bed and bath linens in good condition. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed for smoking, an indwelling urinary catheter and dialysis. This was true for three (3) of 27 residents reviewed for the care area of developing and implementing a comprehensive care plan during the long term care survey process. Resident Identifiers: Resident #99, #102 and #105 . Facility Census: 112. Findings Included: a) Resident #99 On 11/28/22 at 2:53 PM, a list of smokers was provided by the facility. Resident #99's name was on the list. On 11/29/22 at 1:25 PM, a record review was completed for Resident #99. Upon completion of the review, the care plan did not list the smoking status as a focus area. On 11/30/22 at 8:15 AM, the Director of Nursing (DON) confirmed the smoking status was not listed on the care plan. [...]

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to ensure three (3) of four (4) resident's dependent upon staff for bathing activities, received the necessary care and services to maintain good grooming, and personal hygiene. Resident identifiers: #24, #19, and #14. Facility census: 112.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. This failed practice had the potential to affect four (4) of seventeen (17) residents sampled. Resident identifiers: #79, #69 and 115. Facility census: 112.

Inspectors wroteBased on observation, resident council, staff interview, resident interview, record review and sampling of test tray, the facility failed to follow the dietary recipe to meet nutritional value and palatability. This was a random opportunity for discovery and had a potential to affect more than a limited amount of residents receiving nutrition from the facility kitchen. Facility census: 112 Findings Included: a) Chicken Vegetable Soup During the interview process of the Long Term Care Survey Process on 11/28/22 several residents had food concerns about taste and temperature. On 11/29/22 four (4) state surveyors tasted the noon time meal for palatability. The chicken vegetable soup was tasteless and not palatable. On 11/30/22 the Certified Dietary Manager(CDM) #148 provided the recipe for the Chicken Vegetable Soup, -Carrots: eight (8) pounds (lb) -Celery: four (4) lbs -Garlic Cloves: [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, Resident Council meeting interviews, tray temperatures at time of service and a sampled meal, the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature. This had the potential to [NAME] than a limited number of residents at the facility. Facility census:112.

Inspectors wroteBased on meal temperature of each meal prior to serving and staff interview, the facility failed to ensure monitoring records, of temperature logs from the tray line, were completed with each meal. This had the potential to affect more than a limited number of residents. Facility census: 112.

Inspectors wroteBased on staff interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement Committee members attended the meetings. This failed practice had the potential to affect more than a limited number of Residents residing at the facility. Facility census: 112.

Inspectors wroteBased on observation, staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. PPE (Personal Protection Equipment) was not readily available for resident care. Hand hygiene for residents was not provided prior to being served a meal. Staff failed to use hand hygiene between residents being served meals and used unsanitized hands to pick up and butter slices of bread. Respiratory equipment was not stored in a sanitary manner. Resident Identifiers: Resident #5, and #83. Facility census 112.

Inspectors wroteBased on record review and staff interview, the facility failed to designate a qualified individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. This had the potential to affect more than a limited number of residents at the facility. Facility census: 112.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the residents have already been immunized. This was true for 43 of 112 residents residing in the facility. Resident identifiers: #38, #26, #105, #108, #107, #46, #89, #54, #365, #17, #104, #10, #8, #33, #48, #84, #5, #110, #27, #100, #39, #11, #4, #32, #36, #69, #47, #82, #86, #13, #109, #1, #19, #44, #95, #63, #103, #52, #90, #61, #58, #74, and 29. Facility Census: 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of dialysis during the long-term care survey received hemodialysis care consistent with professional standards of practice including ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring the resident's condition during treatments, monitoring for complications, and implementing appropriate interventions. Resident identifier: #105. Facility census: 112.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure the facility physician made all required visits to meet the requirements in frequency/ timeliness. This was true for one (1) out of two (2) residents reviewed for choices. Resident identifier: Resident #23. Facility census 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications were kept in proper temperature controls in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Facility Census: 112. Findings Included: a) Medication Refrigerator On 11/29/22 at 8:55 AM, a tour of the medication room on B wing was completed. There was one incomplete temperature log hanging on the medication refrigerator. The November temperature log was entitled Temperature Log For Medication/Vaccine Refrigerator. The Temperature Log for Medication/Vaccine Refrigerators states record temps (temperatures) twice daily. (Typed as written.) On 11/29/22 at 9:03 AM, Registered Nurse (RN) #135 confirmed the log was incomplete in recording the temperatures for the days in the month of November, 2022. RN #135 stated Those days are missing. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to administer a pneumococcal vaccine after Resident #86 signed a consent on 07/06/21. This was true for one (1) of five (5) residents reviewed for pneumococcal vaccines. Resident identifiers: 86. Facility census: 112.