Fairview Care Center

Inspectors wroteBased on interview and document review, the facility failed to provide proper updates and notification to a resident representative for 1 of 1 residents (R51) reviewed for representative notification.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a medication was administered safely for 1 of 1 resident (R42) who had been assessed as unable to safely self-administer medications.

Inspectors wroteBased on interview, observation and record review the facility failed to develop a person-centered care plan for 1 of 1 resident (R42) reviewed for respiratory cares.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper infection control practices were performed for 2 of 2 residents (R45, R9) who had their blood sugar checks completed with the same glucometer (machine used to check blood glucose).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure unqualified staff did not perform ear cleaning for 1 of 4 residents (R1) reviewed for cares provided by unqualified staff.

Inspectors wroteBased on interview and record review the facility failed to comprehensively assess pressure ulcer (PU) development, implement appropriate interventions to prevent PU's and notify the provider of changes for 1 of 3 residents (R1) who entered the facility without pressure ulcers. This resulted in harm when R1 devleoped a stage 3 pressure ulcer. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure insulin pens were appropriately labeled according to manufacturer's guidelines with an opened date for 1 of 1 observed medication cart for 1 of 1 resident (R28) who required the use of an insulin pen. Furthermore, the facility failed to ensure tuberculin solution was dated when opened. In addition, failed to ensure expired product was not available for administration for 1 of 1 medication room reviewed for medication storage. This had the potential to affect anyone who would be prescribed this medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess residents for their ability to self-administer nebulizer treatments after nurse set up for 1 of 1 resident (R31) observed self-administrating a nebulizer treatment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents with difficulty swallowing were assisted with meals by qualified individuals.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the plan of care after changes to fall prevention measure for 1 of 4 residents (R3) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess and monitor non-pressure related skin injuries (bruises) for changes until resolved for 1 of 3 residents (R1, R2 and R3), reviewed for injury of unknown origin.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered according to physician order for 1 of 1 residents (R5) reviewed for medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately and timely disposition 95 prescribed medications (over 2000 pills) that had been discontinued to prevent potential diversion that were observed in 1 of 1 medication rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed to place an indwelling urinary catheter correctly in 1 of 3 residents (R1) which resulted in discomfort, bleeding, and emergent services.

Inspectors wroteBased on observation, interview and document review the facility failed to complete comprehensive safety assessments for electric lift recliners to prevent and/or reduce falls from electric recliners for 2 of 3 residents (R1, R2) who had falls from electric recliners. Findings Include: R1 admission record dated 12/10/12, identified R1 had diabetes mellitus with diabetic nephropathy, dementia without behavioral disturbances, general anxiety disorder, and asthma. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment with no behaviors. R1 was frequently incontinent of bowel and bladder and was dependent on staff for transfers, toilet use, personal hygiene, and bathing. R1's MDS identified no falls since admission or previous assessment. [...]

Inspectors wroteBased on interview and document review, the facility failed to implement the facility's abuse policy/procedures to report and ensure resident protections from suspected or alleged abuse for 1 of 1 resident (R2) reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure witnessed allegations of physical abuse (rough handling) were reported immediately, within two hours, to the State Agency (SA) for 1 of 1 resident (R2) reviewed for allegations of staff to resident abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents received their mail on Saturdays for 2 of 3 residents (R11, and R25) who attended the resident council meeting. This deficient practice had the potential to affect any resident who received mail.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was labeled, dated, and disposed according to the facility's policy for food storage. This failure had the potential to affect all 45 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure the medication cart was locked and secure for 1 of 2 medication carts (Wing One). As a result of this deficient practice the medications in the cart were unsecured and had the potential for loss or misuse.

Inspectors wroteBased on observation, interview, and document, review the facility failed to ensure an agency nurse, on first day at the facility, was oriented to the specifics of the facility to be able to provide safe resident care for residents in one of two wings (Wing One). As a result of this deficient practice the residents had the potential for harm for staff not understanding the facility processes for safe resident care.

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure the influenza vaccine was given and/or documented refusal for the 2022 influenza season for 2 of 5 residents (R2, R7). As a result of this deficient practice, the resident who did not received the requested influenza vaccine were at higher risk for contracting influenza and the resident without education was not making an informed decisions about choice to receive the influenza vaccine or not.