Prestige Care Center of Fairfield

In the surveyor’s words

From the most serious findings on record at Prestige Care Center of Fairfield, in the surveyor’s own words.

• Immediate jeopardy, isolatedF757Feb 18, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF686Dec 28, 2021

  Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to carry out assessments and interventions in order to prevent the development and/or worsening of a facility acquired pressure ulcer for 3 of 3 residents reviewed for pressure ulcers (Residents #1, #2, and #3). The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 69 residents. Findings include: 1. The MDS (Minimum Data Set) assessment tool, dated 8/18/21, stated the resident had MASD (Moisture Associated Skin Damage-incontinence-associated [CONDITION(S)]/inflammation of the skin). The MDS assessment tool, dated 11/18/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jun 11, 2025

  3. 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. […]

• Actual harm, isolatedF689Nov 1, 2023

  Based 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. […]

• Actual harm, isolatedF689May 9, 2023

  Based on observation, clinical record review, policy review, and staff interviews, the facility failed to create and implement fall interventions based on root cause analysis of previous falls for 3 of 3 residents reviewed for falls(Residents #2, #3, and #5) and failed to ensure the proper disposal of a needle for 1 of 1 needle-related incident reviewed. The facility reported a census of 64 residents. Findings Include: 1. The Minimum Data Set(MDS) assessment tool, dated 3/13/23, listed diagnoses for Resident #2 which included stoke, hip fracture, and a history of falling. The MDS documented the resident required limited assistance of 1 staff for transfers, walking, dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. […]