Prestige Care Center of Fairfield

Inspectors wroteBased on a facility list of residents who utilized a mechanical lift, policy review, and staff interviews, the facility failed to launder mechanical lift slings according to manufacturer instructions for 11 of 11 residents who utilized mechanical lift slings. The facility reported a census of 54 residents.

Inspectors wroteBased on observation, facility policy review and staff interview, the facility failed to ensure dietary staff prepared and served food in accordance with safe hygienic practices to prevent cross-contamination of foods for 1 of 1 observation of a meal service. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of pneumococcal and/or influenza vaccines and/or obtain informed consents or declinations for the vaccines for 5 of 5 residents reviewed for immunizations(Residents #2, #8, #10, #21, and #23). The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of COVID-19 vaccine for 1 of 5 (Resident #10) residents, and failed to obtain an informed consent or declination for the vaccine for 5 of 5 (Resident #2, Resident #8, Resident #10, Resident #21, and Resident #23) residents reviewed for immunizations The facility reported a census of 54 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff treated residents with dignity and respect for 2 of 18 sampled residents (Residents #13 and Resident #40). The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff informed the residents and families of the risks, benefits and side effects of psychotropic medications prior to the administration of those medications for 3 of 3 residents sampled (Residents #54, #7 and #11). The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident representative and staff interviews, the facility failed to notify the family and the physician that 1 of 1 resident (Resident #21) reviewed for notification missed six doses of an anti-anxiety medication scheduled for administration two times daily. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident reviewed for abuse (Resident #40). The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 1 resident (Resident #40) reviewed for abuse. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to provide bed hold notices for 2 of 3 residents (Resident #10 and Resident #60) reviewed for hospitalizations. The facility reported a census of 54 residents.

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy, the facility failed to identify and assess a non pressure skin wound for 1 of 2 residents (Resident #1) reviewed for wounds. The facility reported a census of 54 residents.

Inspectors wroteBased on record review, staff interviews, and the facility policy, the facility failed to complete pre and post dialysis assessments 1 of 1 resident (Resident #5) review for dialysis. The facility reported a census of 54 residents.

Inspectors wroteBased on record review and staff interviews, and the facility policy, the facility failed to perform annual evaluations for 2 of 3 certified nursing assistants reviewed for performance reviews. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of a routine medication for 1 of 7 residents reviewed for medications (Resident #9). The facility reported a census of 54 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure a medication error rate less than 5 percent when a medication administration observation resulted in a 7 percent error rate. The facility reported a census of 54 residents.

Inspectors wroteBased on clinical record review, facility policy review, provider and staff interviews, the facility failed to reorder a medication and utilize the emergency pharmacy stock in an effort to prevent a resident from missing six doses of an anti-anxiety medication for 1 of 11 residents (Resident #21) reviewed for medication administration. The facility reported a census of 54 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure that dietary staff served meals that met the therapeutic needs (Resident #18) and preferences (Resident #49) for 2 of 5 residents reviewed for diet orders. The facility reported a census of 54 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure staff performed hand hygiene during glove changes to prevent the potential spread of infection for 1 of 3 residents observed for wound care treatment (Resident #20). The facility reported a census of 54 residents.

Inspectors wrote3. The MDS assessment tool, dated 5/12/25, listed diagnoses for Resident #13 which included Alzheimer's disease, non-Alzheimer's dementia, and Parkinson's disease(a disorder which caused tremors and difficult mobility). The MDS listed her cognition as severely impaired. A 2/15/25 Care Plan entry stated the resident was at risk for falls related to confusion. On 6/3/25 at 9:56 AM, Resident #13 sat in a shower chair in her room. The door was open and no staff were within sight of her. At 10:12 AM Staff A Registered Nurse(RN) and Staff R Certified Nursing Assistant(CNA) walked by the resident's room and Staff A asked Staff R if she just finished the resident's shower. Staff R said no she had been done. Staff R closed the resident's door and they both walked away. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to administer medications within the timeframe directed by the manufacturer/pharmacist for 3 of 8 residents (Resident #31, #41, #53) reviewed for medications, and failed to follow professional standards of medication administration by ensuring the same staff member set up medications as who administered them for 1 of 8 residents reviewed for medication administration (Resident #52). The facility reported a census of 59 residents.

Inspectors wroteBased on review of nursing staff schedules, list of CPR (cardiopulmonary resuscitation) certified staff, facility policy and staff interview the facility failed to ensure CPR certified staff available in the facility 24 hours per day, 7 days per week. The facility reported a census of 59 residents.

Inspectors wrote5. During a continuous observation on 6/5/25 at 3:05 PM, in the Bonnefield Unit call lights visualized activated above the door for Resident #12 and Resident #38 room. At 3:11 PM, Staff M, CNA, came out of the shower room with Resident #17. Staff M pushed the resident in a shower chair down the hall and passed by Resident #12 and Resident #38's room. Staff M heard commenting to Resident #17 that she was going to take her to her room and then see what the others needed. Staff M took Resident #17 into her room and shut the door At 3:11 PM, Resident #14 activated her call light. No staff observed in hallway. At 3:17 PM, Staff M, CNA, exited Resident #17's room, walked down the hallway past Resident #12's and Resident #38's room to the shower room, entered the shower room, and exited with a blow dryer. Staff M, CNA, returned back to Resident #17's room. [...]

Inspectors wroteBased on observations, facility policy review, and staff interview, the facility failed to ensure sanitary kitchen conditions in an effort to prevent cross contamination during 2 of 2 meals observed. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to ensure staff treated residents with dignity by not providing a meal in a timely manner for 1 of 5 residents reviewed for dignity (Resident #41) and failed to ensure the provision of a catheter dignity bag for 1 of 3 residents reviewed for catheters (Resident #42). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure self medication administration assessments were completed. for 2 of 2 residents reviewed for self medication safety (Resident #23 and Resident #7). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, staff interview, and clinical record review the facility failed to ensure consistent communication and clarification of resident code status, either to perform cardiopulmonary resuscitation (CPR) or Do Not Resuscitate (DNR), for 1 of 1 residents reviewed for code status (Resident #44). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility policy review the facility failed to provide privacy during an enteral tube feeding for 1 of 1 residents (Resident #53) reviewed for privacy. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, interview, and clinical record review, the facility failed to ensure targeted behaviors were identified for the use of antipsychotic medication for 1 of 6 residents (Resident #11) reviewed for unnecessary medications. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interviews, the facility failed to report allegations of abuse per regulatory guidelines for 3 of 3 potential incidents (involving Resident #15 & Resident #21, Resident #165 and a staff member, and Resident #61 & Resident #42) reviewed for abuse. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure an ongoing discharge planning process for 1 of 1 resident reviewed for discharge (Resident #215). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to revise Care Plans to include significant resident information related to significant weight loss, severe allergies, wheelchair safety and change in advanced directive status for 4 of 21 residents (Resident #7, Resident #15, Resident #44, Resident #52) reviewed for Care Plans. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure the provision of an adequate number of baths for 2 of 2 residents reviewed for bathing assistance(Residents #5 and #43). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to assess and intervene for 2 of 2 residents (Resident #36 and #41) with high blood sugar results. The facility reported a census of 59 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions to prevent and treat pressure ulcers for 1 of 3 residents reviewed for pressure ulcers (Resident # 52). The facility reported a census of 59 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to use Enhanced Barrier Precautions and infection control techniques during catheter care, and intervene in a timely manner reports of an indwelling catheter leaking for 1 of 1 residents (Resident #7) reviewed with an indwelling catheter. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to notify the physician and carry out interventions in a timely manner after a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident #52). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure consistent completion of post dialysis assessments for 1 of 1 residents reviewed (Resident #44) for dialysis. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure the provision of therapy services for 1 of 2 residents reviewed for specialized services (Resident #23). The facility reported a census of 59 residents.

Inspectors wroteBased on review of the Resident Matrix, the facility policy, the Facility Assessment, and staff interview the facility failed to ensure the Facility Assessment identified and addressed the specialized staff training and supply needs for residents in the facility who currently receive hemodialysis (treatment to filter waste and excess fluids from the blood and kidneys) and receive nutrition, hydration and mediations through the use of an enteral tube (a tube surgically inserted through the abdomen into the stomach, specifically a gastrostomy tube or G-tube). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in the resident's room when a pervasive urine odor present in the resident's room for one of one resident reviewed for environment (Resident #9). The facility reported a census of 59 residents.

Inspectors wroteBased on observation, facility policy review, and staff interview, the facility failed to post the facility census and nurse staffing information on a daily basis. The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to follow physician orders for warfarin administration, also known as Coumadin, after one of three residents (Resident #3) had an elevated International Normalized Ratio (INR) lab result of 6.7 on 1/17/25. Previous to this INR result, Resident #3 had an order for warfarin 5.5 mg daily, with a goal of a therapeutic INR range of 2.5 to 3.5. After an INR result of 6.7, a physician order was given to hold Resident #3's warfarin dose on 1/17/25, and starting on 1/18/25 decrease the daily dose from 5.5mg to 5.0mg daily. The Medication Administrator Record (MAR) documented a 5.5mg dose of warfarin administered to Resident #3 on 1/17/25, and 5.5 mg warfarin doses administered on 1/18/25, 1/19/25, and 1/20/25. On 1/21/25, Resident #3 had a repeat INR test with a result of 12.4. [...]

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to maintain a clean and sanitary environment. (Resident #3, #5). Facility reported census was 62.

Inspectors wrote§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation Based on clinical record review, facility policy and staff interview, the facility failed to complete shift change controlled substance counts with the required two licensed nurses per facility policy. The facility reported census was 65.

Inspectors wrote§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Based on clinical record review, facility policy and staff interview, the facility failed to ensure custody of medication cart keys were only accessible to authorized personnel. The facility reported census was 65.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to accurately code antiplatelet medication, insulin, and hospice services for 4 of 23 residents reviewed for Minimum Data Set (MDS) assessment (Residents #21, #22, #25, and #34). The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a comprehensive individualized care plan that accurately reflected the resident's plan of care for 4 of 23 residents reviewed (Residents #22, #25, #28, and #60). The review of the 4 residents Care Plans failed to address diabetes, a peripherally inserted central catheter (PICC), use of antibiotics, wounds, hospice level of care, and use of oxygen therapy. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to have enough staff in the dining room during lunch to assist residents with eating and help a resident out of the dining room to the bathroom. This resulted in an incontinent episode in the dining room for 4 of 10 residents reviewed for insufficient staffing (Residents #17, #33, #41, and #45). The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they followed the for residents who received a pureed diet. The meal lacked pureed cornbread as directed on the menu for one of one observation of the puree process. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. In addition, the facility failed to test the low temperature dish machine temperature and chemical level. The facility reported a census of 61 residents.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to give the resident meal choices prior to the meals for 1 of 1 resident reviewed for choices (Resident #58). The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to notify the Ombudsman of a resident's hospitalization for 1 of 2 residents reviewed for hospitalization (Resident #28). The facility reported a census of 61 residents.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to follow the special recommendations as directed by the Preadmission Assessment Screening and Resident Review (PASRR) Level II for 1 of 2 residents reviewed (Resident #34). In addition, the facility failed to submit the PASRR level II in a timely manner for 2 of 2 residents reviewed (Residents #2 and #34). The Level II Special Recommendations directed the facility to designate a Power of Attorney (POA) for Resident #34. The facility reported a census of 61 residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a resident received their medication. In addition, the facility failed to ensure the Certified Medication Aide (CMA) administered a resident's medication under their name and did not hold the medication cup in their hand in their shirt pocket prior to administration to the resident for 2 of 2 residents reviewed for professional standards (Residents #33 and #45). The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow-up after a resident had documentation of no bowel movement from 6/17/24 through 6/23/24. In addition, the facility failed to perform adequate assessment of a non pressure wound for two of three residents reviewed for assessment and intervention (Residents #3 and #51). The facility reported a census of 61 residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to keep a resident free from injury while repositioning them in bed for 1 of 3 residents reviewed for accidents (Resident #22). This resulted in Resident #22's head hitting the bed rail. The incident caused a bruise to Resident #22's forehead. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility policy review, the facility failed to follow the physician's order for continuous administration of oxygen for 1 of 3 residents reviewed (Resident #12) for respiratory care. The facility reported a census of 61 residents.

Inspectors wroteBased on staff interview, review of CMS 2567 reports, and facility Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during the surveys completed in the last fifteen months. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to serve mandarin oranges at the appropriate temperature; they failed to serve the room trays at the appropriate temperature; and touched food on a plate with gloves and did not remove the gloves after handling the food or wash their hands. The facility reported a census of 60 residents.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to notify the physician when a resident's blood glucose over 450 mg/dl (milligrams/deciliter) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 60 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to answer a call light in less than 15 minutes for 1 of 3 residents reviewed for insufficient number of staff (Resident #1). The facility reported a census of 60 residents.

Inspectors wroteBased on observation, interview, record review, and the facility policy the facility failed to report an allegation of resident to resident sexual abuse in a timely manner and failed to report facial bruising of an unknown origin for 3 of 3 residents reviewed for abuse reporting (Residents #1, #2, and #3). The facility reported a census of 66 residents.

Inspectors wroteBased on observation, record review, interviews, and the facility policy the facility failed to thoroughly investigate facial bruising of unknown origin for 1 of 3 resident reviewed for inadequate nursing supervision. The facility reported a census of 66 residents.

Inspectors wroteBased on observation, record review, and staff, resident responsible party and State Climatologist interviews, the facility failed to ensure resident safety and prevent a resident's elopement, when they failed to identify a resident's change in condition and actions that placed the resident at high risk for elopement, for 1 of 9 resident records reviewed (Resident #8). Resident #8 eloped from the facility and 0.7 miles away from the facility when located by staff approximately 20 to 25 minutes after he was last observed at the main entrance door. The facility reported a census of 68 residents.

Inspectors wroteBased on observation, record review, and staff and Fire Marshall interviews, the facility failed to follow Life Safety Code regulations (mandated by the Fire Marshall) when they applied a combination lock to 1 of their fire exit/egress doors on 10/3/23, without consultation with or authorization from the State Fire Marshall. The lock prevented the fire exit door from opening unless a code was entered, the lock remained on the door through 10/26/23 and was a direct violation of Life Safety Code regulations. The facility reported a census of 68 residents.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to ensure all residents received the correct medications, as ordered and directed by their physicians, for 1 of 9 residents reviewed (Resident #2). The medication administered to Resident #2 in error were intended for Resident #3, and resulted in a delay of analgesic medication administration for Resident #3. The facility reported a census of 68 residents.