Fair View Health Care Center

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's census was 53. The administrator was notified on 7/6/26 of Past Non-Compliance which occurred on 6/25/26. The administrator and Director of Nursing investigated, notified responsible parties, and in-serviced staff regarding abuse and notifying management, terminated alleged perpetrator and had additional monitoring for the resident. Staff corrected the deficient practice on 6/26/26. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings for two residents (Resident #39, and #51) out of three residents. The census was 53.1. Review of the facility's Skilled Nursing Facility Resident Agreement, undated, showed the facility under no circumstances will be held responsible for or have any liability of any nature whatsoever for loss or damage to valuables, personal property or money brought to facility. It is further agreed that no deductions or credits shall be taken from any amount due or owing to facility as a result of any loss suffered or damage done by residents to personal property. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services (DFNS) with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 53.1. Review of the facility's Dietary Manager (DM) job description, dated 2023, showed the DM must meet State requirements for food service managers or dietary managers, and also meet one of the following qualification requirements: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the walk-in freezer in a manner to prevent potential food contamination. This failure has the potential to affect all residents. The facility census was 53.1. Review of the facility policies provided showed they did not contain a policy related to maintenance of the walk-in freezer. Observation on 04/19/26 at 10:24 A.M., showed the walk-in freezer door unable to fully seal shut. Observation showed a thick frost accumulation on the freezer walls, evaporator coil cabinet and on most of the food stored inside the freezer. Observation also showed a thick layer of ice on the front and back of the evaporator coil cabinet and on the floor inside the freezer. Observation on 04/20/16 at 10:18 A.M., showed the walk-in freezer door unable to fully seal shut. [...]

Inspectors wroteBased on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data for the first and second quarter of 2025. The facility census was 53.1. Review of the facility's Registered Nurse (RN) policy, revised 04/30/24, showed the facility is responsible for submitting timely and accurate staffing data through the CMS PBJ system. 2. Review of the facility's CMS PBJ Staffing Data Report, dated April 17, 2026, did not contain a report for the first and second quarter of 2025. 3. During an interview on 04/22/2026 at 4:07 P.M., the Director of Nursing (DON) said their corporate office is responsible for reporting staffing information to the PBJ. He/She said he/she was not aware the PBJ wasn't reported correctly for 2025. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure the two-step purified protein derivative (PPD), a skin test for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) was completed and on file in accordance with the facility policy for five employees (Dietary Aide M, Licensed Practical Nurse (LPN) N, [NAME] O, Certified Medication Technician (CMT) P, and Registered Nurse (RN) E out of 10 employee files reviewed. Staff failed to ensure all residents were screened for TB when staff failed to ensure a two-step PPD and/or annual PPD tests were completed and documented per the facility policy for four residents (Resident #3, #10, #26, and #35) of five sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for four residents (Resident #4, # 5, #10, and #22) out of 16 sampled residents. The facility census was 53.1. Review of the Facility's Comprehensive Care Plan Policy, revised 10/31/24, showed the care planning process will include an assessment of the resident's strengths and needs, and cultural preferences in developing goals of care. The Care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS), a federally mandated assessment tool, assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 53.1. Review of the Facility's RN policy, revised 4/30/24, showed the facility will utilize the services of a RN for at least eight consecutive hours per day, seven days a week. 2. Review of the facility's RN staff schedule, dated January 2026, showed the facility did not have an RN in the building on: -Saturday, 01/03/26; -Sunday, 01/04/26; -Saturday, 01/17/26; -Sunday, 01/18/26; -Saturday, 01/31/26. 3. Review of the facility's RN staff schedule, dated February 2026, showed the facility did not have an RN in the building on: -Sunday, 02/01/26; -Saturday, 02/14/26; -Sunday, 02/15/26; -Saturday, 02/28/26; -Sunday, 02/29/26. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure four Nurse Aide's (NA) (NA A, NA B, NA C and NA D) of four completed the nurse aide training program within four months of his/her employment in the facility. The census was 53.1. Review of the facility's policies showed staff did not provide a policy that directed staff on NA qualifications. 2. Review of NA A's Certified Nurse Aid (CNA) report showed a hire date of 09/15/25. The report did not contain documentation NA A completed a nurse aide training program. 3. Review of NA B's CNA report showed a hire date of 08/23/25. The report did not contain documentation NA B completed a nurse aide training program. During an interview on 04/22/26 at 10:51 A.M., NA B said he/she started in August of 2025 and has never worked in any other department. He/She said he/she started classes a few months ago. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications not in use and expired medications were properly discarded. The facility census was 53.1. Review of the facility's policy, Storage of Medications, dated 05/18/24, showed medications housed in the facility premises and follow in accordance the manufacturer's recommendations related to unused medications. 2. Observation on 04/19/26 at 10:30 A.M., showed the 200 hall medication cart contained: -One bottle of Prednisolone Acetate 1% Ophthalmic Suspension five milliliter (mL) (steroid eye drop) with an expiration date of 04/15/26; -One bottle of Systane Balance Lubricant Eye Drops 0.5%, 10 mL with an expiration date of 02/12/26; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit ( F) or higher upon service to residents who ate in their rooms. The facility census was 53.1. Review of the facility's policy titled, Dietary Food Preparation, dated 07/05/23, showed the temperature of hot food items are expected to be greater than 135 F at the time of service to residents. During an interview on 04/19/26 at 12:50 P.M., Resident #23 said he/she eats in his/her room. The resident said when staff bring his/her food the food is barely warm and he/she prefers his/her food to be hot. During an interview on 04/19/26 at 1:11 P.M., Resident #43 said his/her food is mostly cold when delivered. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over four residents (Resident #4, #22, #23 and #34) while assisting the residents to eat. The facility census was 53.1. Review of the facility's Promoting/Maintaining Resident Dignity policy, revised 09/21/25, showed all staff will speak to and treat all residents with dignity and respect, all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, and when interacting with a resident, pay attention to the resident as an individual.2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete or post required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 53.1. Review of the facility's policy titled, Nurse Staffing Posting Information Policy, reviewed 06/26/24, showed the nurse staffing sheet will be posted on a daily basis and will contain: -Facility Name; -Current date; -Facility current resident census; -The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directedly responsible for resident care per shift: -Registered nurses (RN); -Licensed Practical Nurses (LPN)/Licensed Vocational Nurses (LVN); -Certified nurse aides (CNAs). -The facility will post the Nurses Staffing Sheet at the beginning of each shift. [...]

Inspectors wroteBased on interview and record review, facility staff failed to have a Registered Nurse (RN) for eight consecutive hours a day that was not the Director of Nursing (DON) with a facility census over 60 residents. The facility was 64.1. Review of the facility's Registered Nurse Policy, revised 4/30/24, showed staff are directed the DON may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. 2. Review of the facility census and staffing sheets, dated 7/15/25 to 7/31/25, showed the following: -7/20/25 showed a facility census of 61, and DON worked as a charge nurse;-7/24/25 showed a facility census of 61, and DON worked as a charge nurse;-7/29/25 showed a facility census of 61, and the DON worked as a charge nurse. 3. Review of the facility census and staffing sheets, dated 8/1/25 to 8/20/25, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to meet professional standards when staff did not complete weekly skin assessments and did not document they provided physician ordered wound treatments for three residents (Residents #1, #2, and #3) out of six sampled residents. The facility census was 61. 1. Review of the facility's Skin Assessment Policy, dated 6/26/24, showed licensed or registered nurse will conduct a full body, or head to toe, skin assessment upon admission, or re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/5/25, showed staff assessed the resident as: -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, facility staff failed to update their Facility-Wide Assessment, an assessment completed by facility staff to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies as necessary. The facility census was 59. 1. Review of the facility's Assessment Tool, dated 9/5/24, showed the purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Staff are directed as follows: -Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered baseline care plan to meet the resident's medical, nursing, mental and psychosocial needs for one resident (Resident #1) out of two sampled residents. The facility's census was 52. 1. Review of the facility's Baseline Care Plan Policy, dated 5/18/24, showed the baseline care plan will be developed in 48 hours of a resident's admission. It should include the minimum healthcare information necessary to properly care for a resident. The admitting nurse, or supervising nurse on duty, shall gather infoamtion form the admission physical assessment, hospital transfer information, physicain orders, and discussion with teh residnt and resident representative. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to meet professional standards when staff did not obtain orders for a urinary catheter (flexible tube used to drain the bladder when someone cannot urinate on their own), catheter care, for a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe), tracheosyomy care, and did not obtain orders for a Gastrostomy (a surgical procedure creating an opening through the abdominal wall into the stomach, allowing for the insertion of a gastrostomy tube for feeding) tube, Gastrostomy tube flushes, or Gastrostomy tube care for one resident (Resident #1) out of five sampled residents. The facility census was 52. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to perform hand hygiene and/or wash hands to prevent the spread of infection during medication pass for five residents (Residents #3, #20, #29, #41, and #48) of six sampled residents, and during perineal care for two residents (Resident #22 and #38) of two sampled residents. Facility staff failed to follow infection control protocols for cleaning/disinfecting the glucometer (a device used to measure blood sugar levels) when staff tested four residents (Resident #23, #26, #31, and #58) of four sampled resident blood sugar levels. [...]

Inspectors wroteBased on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident), criminal background check (CBC), and Family Care Safety Registry (FCSR) prior to hire in accordance with their facility policy for nine (Registered Nurse (RN) E, Nurse Aide (NA) D, Certified Medication Technician (CMT) F, Dietary Aide G, laundry aide H, housekeeping aide I, maintenance J, Certified Nurse Aide (CNA) K, and CNA L) out of ten sampled employees. The facility census was 53. 1. Review of the Facility's Screening- Applicant, Employee, Volunteer and Vendor (Missouri) policy, Revised May 2024, showed: -HR staff will conduct the following screens on potential employees prior to hire; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure acceptable standards of practice when staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for two of four sampled residents (Resident #3, and #18). Ensure pressure relieving devices were in place for two out of three sampled residents (Resident #20, and #22). Staff failed to provide wound care treatment per physician orders for one out of one sampled resident (Resident #40). The census was 53. 1. Review of the facility's Head Injury policy, revised 05/18/2024, showed staff are directed as follows: -Assess resident following a known, suspected or verbalized head injury. The assessment shall include, at a minimum: a. Vital signs. b. General condition and appearance. c. Neurological evaluation for changes in: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide adequate baths/showers to maintain proper hygiene for four residents (Resident #15, #26, #37, #38) out of seven sampled residents, and one additionally sampled resident (Resident # 35), who required assistance from staff to complete their Activities of Daily Living (ADLs) (bathing, showering, dressing, transfers, toileting, etc.). The facility census was 53. 1. Review of the facility's Resident Showers Policy, revised 06/26/24, showed the purpose is to assist residents with bathing to maintain proper hygiene, and directed staff as follows: -Resident will be provided showers as per request or as per facility schedule protocols and based upon resident safety; -Partial baths may be given between regular shower schedules as per facility policy; -Assist the resident with showering as needed. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing activity program to meet the needs, interests, and physical, mental, and psychosocial well-being for four (Resident #23, #44, #48, and #58) out of 14 sampled residents on weekends. The facility staff failed to post an activities calendar for residents to view. The facility census was 53. 1. Review of the facility's policy titled, Activities, dated 07/23, showed the facility will provide an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being. Review showed staff were directed to: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5%. Out of 29 opportunities observed, six errors occurred, resulting in a 20.69% error rate, which effected four residents (Resident #23, #26, #31, #58) out of ten sampled residents. The facility census was 53. 1. Review of the Facility's Medication Errors policy, dated [DATE], showed the facility shall ensure medications will be administered as follows: -According to physician orders; -In accordance with accepted standards and principles which apply to professionals providing services; -The facility must ensure that it is free of medications error rates of 5% or greater as well as significant medication error events; -The facility will consider factors indicating error in medication administration, including, but not limited to, the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #22, #36, and #47) out of three sampled residents. The facility's census was 53. 1. Review of the facility policies showed staff did not provide a policy for bed hold notification. 2. Review of Resident #22's medical record showed the resident discharged from the facility on 07/10/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #36's medical record showed the resident: -discharged on 08/08/24 and readmitted to the facility on [DATE]; -discharged on 06/22/24 and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interviews and record review, facility staff failed to ensure Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASRR) level II screen is required) were completed for two residents (Resident #8, and #26) out of two sampled residents. The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for PASRR. 2. Review of the Central Office Medical Review Unit (COMRU) website, https:// health.mo.gov/seniors/nursinghomes/pasrr.php, dated 09/04/24, showed the PASRR is a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #10, #27, and #40) out of 14 sampled residents. The facility census was 53. 1. Review of the facility's policy titled, Call Light Accessibility and Timely Response, dated 4/30/24, showed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All residents will be evaluated on how to call for help by using the resident call system. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The call system should be accessible to a resident lying on the floor. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure residents have appropriate access to their trust fund account to include on the weekends. The facility census was 53. 1. Review of facility's Resident Trust Policy, dated 02/02/24, showed the facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday. Review of the facility's admission Packet, undated, showed the facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday. During an interview on 08/28/24 at 9:40 A.M., the Corporate Business Office Manager said the corporation policy states resident access to funds is during business hours Monday through Friday. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop a detailed facility assessment, to include the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs during day-to-day operations and emergencies. The facility census was 53. 1. Review of the facility policies showed staff did not provide a policy for the facility assessment. 2. Review of the Facility Assessment Tool, dated 01/20/24, showed the following: -Special Treatments and Conditions: Oxygen therapy 5; Tracheostomy Care 1; Bilevel positive airway pressure (BIPAP)/Continuous positive airway pressure (CPAP): 3; Behavioral Health care needs 12; Injections 8; Dialysis 1; Ostomy Care 1; Hospice Care 2. -Assistance with Activities of Daily Living was left blank; -Number of licensed Nurses per resident was left blank; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure ten Nurse Aides (NA) (NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J) completed the nurse aide training program within four months of their employment in the facility. The facility census was 50. 1. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Policy Statement: Nurse aides must undergo a state-approved training program; -Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. This term may also include an individual who provides these services through an agency or under a contract with the facility, but is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay; [...]

Inspectors wroteBased on interview and record review the facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 50. 1. Review of the facility's Nursing Services Policy, revised 05/01/23, showed the facility will ensure that a registered nurse is on duty to provide RN services at least 8 consecutive hours, 7 days a week. 2. Review of RN A's payroll detail report, dated 9/24/23 - 10/8/23 showed the following hours worked: -On 10/05/23 RN A worked 12:00 A.M. and clocked out at 7:00 A.M.; -On 10/07/23 RN A did not work any hours; -On 10/08/23 RN A did not work any hours. Review of the Nurses schedule, dated 10/01/23-10/31/23, showed RN A was scheduled as follows: -On 10/05/23 RN A was scheduled to work 6:00 P.M. to 6:00 A.M.; -On 10/07/23 RN A was scheduled off; -On 10/08/23 RN A was scheduled off. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 47. 1. Review of the facility's Handwashing/Hand Hygiene policy dated August 2019, showed the policy directed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water after handling contaminated equipment; after contact with objects in the immediate vicinity of the resident; before and after glove use; and before and after eating or handling food; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care for one resident (Resident #5) after the completion of Quarterly Minimum Data Set (MDS), a federally mandated assessment tool. Additionally, staff failed to review and revise the plan of care with changes in the resident's needs for six residents (Resident #3, #4, #10, #23, #24 and #44). The facility census was 47. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, showed staff were directed to do the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Reflects currently recognized standards of practice for problem areas and conditions; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekends. The facility census was 47. 1. Review of the facility's policy titled, Activity Programs Staffing, revised June, 2018, showed staff were directed to do the following: -Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident; -Sufficient activity personnel are on duty to meet the needs of the residents and functions of the activity programs; -When a qualified professional is not on premises, the day-to-day functions of the activity programs are under the supervision of an assistant activity director/coordinator or another facility staff member as designated by administration; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure three residents (Resident #5) had an appropriate indication for the use of antipsychotic medications. Additionally, staff failed to provide a 14-day stop date for as needed (PRN) antianxiety medication, for four residents (Residents #3, #14, #44, and #46). The facility census was 47. 1. Review of facility's policy Psychotropic Medication Use, dated July 2022, showed staff were directed to do the following: -Resident will not receive medications that are not clinically indicated to treat a specific condition; -Psychotropic medication management, includes indication for use. -PRN orders for psychotropic medications are limited to 14 days; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a correct count of controlled medications for three residents (Resident #14, #42 and #3). The facility census was 47. 1. Review of facility's policy Controlled Substances, dated April 2019, showed staff were directed to do the following: -The nurse administering a controlled medication, is responsible for documenting the quantity of the medication remaining; -Controlled medications are counted at the end of each shift; -The nurse coming on duty and the nurse going off duty determine the count together; -Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing (DON) immediately. 2. [...]

Inspectors wroteBased observation, interview and record review, facility staff failed to ensure one resident (Resident #17) with contractures (changes to joint tissues that can lead to tightening, and immobility) received appropriate treatment and services to prevent further decrease in range of motion (ROM) (motion of a joint). The facility census was 47. 1. Review of the facility's policy titled, Resident Mobility and Range of Motion, revised July, 2017, showed staff were directed to do the following: -Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM; -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable; [...]

Inspectors wroteBased on observations, interviews, and record review, facility staff failed to obtain orders for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), or have a system in place for ongoing communication with the dialysis clinic for one resident (Resident #10) who receives dialysis. Additionally, facility staff failed to monitor or assess the resident before and after dialysis treatments. The facility census was 47. 1. Review of the facility's policy titled, Hemodialysis Access Care, dated September 2010, showed staff were directed to do the following: -The dressing change is done in the dialysis center post-treatment; -If dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure; -Mild bleeding from site (post-dialysis) can be expected. [...]