Fairview Rehab and Care Center

Inspectors wroteBased observations of the physical environment of the main kitchen and first floor dining room, reviews of pest control reports, interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program to ensure that the building was free of pests and rodents.

Inspectors wroteBased on observation, and interview with residents and staff, the facility failed to ensure safe, clean, comfortable and homelike environment on one of two nursing floors. (Second floor)Findings Include: Review of facility policy titled Homelike Environment with a revised dated of February 2021 state, Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy states, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. Observations of the Second floor on March 31, 2026, between 10:15 a.m. - 10:40a.m. revealed the following: [...]

Inspectors wroteBased on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on the three of three nursing units. (First, Second, and Third Floors).

Inspectors wroteBased on observations, resident and staff interviews, and facility policy it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (First floor and 3rd floor shower room)Findings Include:Facility Policy titled Cleaning and disinfecting Resident's Rooms last revised on August 2013 stated the purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. Housekeeping surfaces will be disinfected on regular bases and when surfaces are visibly soiled. Under bulletin #6 it stated floor mopping solution will be replaced every three resident rooms or changed no less often than at 60 minutes intervals. Observation of first floor nursing unit on January 6, 2026, 11:34 a.m. revealed there was a strong odor of urine in the hallway of the 1st unit as you get on the unit. [...]

Inspectors wroteBased on interviews with residents and staff, and review grievance, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns for 1 of 1 resident interviewed (Resident R145) and facility did not share the results of the grievances resolution to 15 of 15 residents reviewed during the resident council (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, R146).

Inspectors wroteBased on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to ensure that residents were free of misappropriation of resident property related to diversion of narcotic medication for four of four residents reviewed who were prescribed narcotic medications. (Resident R36, R53, R83, R165).

Inspectors wroteBased upon interviews with facility staff, review of clinical records, facility documentation and policy it was determined that the facility failed to ensure a complete and thorough investigation was completed to rule out neglect when one resident slipped on a wet floor and sustained a fracture for one of 32 resident records reviewed (Resident R90).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that included the minimum information necessary to properly care for one of four resident care plans reviewed (Resident R162). Review of facility policy Care Plans-Baseline, revised 2022, revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:a. [...]

Inspectors wroteBased on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility did not ensure that that professional standards of quality were met related to blood pressure management for one of 32 residents (Resident R36). Based on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility did not ensure that that professional standards of quality were met related to blood pressure management for one of 32 residents (Resident R36).

Inspectors wroteBased on review of clinical records, interviews with staff and review of facility documentation revealed the facility failed to give one resident diagnosed with Alzheimer Disease and a history of wandering adequate supervision when found in a restricted area for one of 32 residents (Resident R129).

Inspectors wroteBased on clinical record review, and interviews with staff and residents, it was determined that the facility did not ensure that medication was administered according to the physician's order for one of 32 residents reviewed (R65). During an interview on January 6, 2026, at 11:30 a.m., resident R65 stated that she had recently been on antibiotic drops for an ear infection, but that she had not received multiple doses. She stated that one of the nurses informed her that the drops could not be located, but the nurse had requested a pharmacy refill. The resident stated that no one ever came back and gave her the missing doses. Review of clinical documentation revealed that resident R65 was admitted to the facility on [DATE], with diagnoses including, but not limited to, asthma, hypertension, and arthritis. [...]

Inspectors wroteBased on observations, facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that the first floor nursing unit was adequately equipped with a functional resident call bell system for one out of the three units observed. (First Nursing Unit).

Inspectors wroteBased on observation, review of facility records, and interviews with staff and residents, it was determined that the facility did not maintain an adequate pest control program related to insects for three of three units reviewed (1st floor, 2nd floor, and 3rd floor). Findings Include: Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnosis including, but not limited to, malignant neoplasm (cancer) of the rectum and colon, and hypertension. Review of his most recent comprehensive MDS (Minimum Data Set- a periodic assessment of resident needs) completed on September 25, 2025, revealed the resident to have a BIMS score (Brief Interview for Mental Status- an assessment of the resident's cognitive state) of 15 out of a possible 15, indicating that he was cognitively intact. [...]

Inspectors wroteFindings Include: A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. [...]

Inspectors wroteBased on interview with staff, it was determined that the facility failed to provide a copy of a resident's medical and financial records upon request by the resident one of one clinical record reviewed. (Resident R1)

Inspectors wroteBased on clinical records reviewed and staff interview, it was determined that the facility failed to ensure that a resident's urinary catheter's bag was maintained in sanitary condition for one of one resident reviewed. (Resident R1)

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure that the facility was adequately equipped resident call system for the second floor nursing unit, 7 out of 7 residents reviewed (Resident R1, R2, R3, R4, R5, R6 and R7).

Inspectors wroteBased on the review of clinical records and interviews with staff it was determined that the facility failed to ensure a complete and thorough investigation was conducted into a resident's allegation of a fall for 1 out of 2 residents reviewed (Resident R1)

Inspectors wroteBased on the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a history of substance abuse for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure that one resident had a physician's order for a leave of absence from the facility for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to notify the physician of a significant change in the resident's condition for one of three residents reviewed (Resident R1). Findings Include: Review of facility policy Change in a Resident's Condition or Status revised February 2021 revealed the nurse will notify the resident's attending physician, or physician on call, when there has been a significant change in the resident's physical/emotional/mental condition. Per the facility policy, a significant change of condition is a major decline, or improvement, in the resident's status that will not normally resolve itself without intervention. [...]

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to maintain complete and accurate clinical record documentation for two of three residents reviewed (Resident R1 and R2). Findings Include: Review of Resident R1's clinical record revealed a physician order dated July 2, 2025, for daily respiratory assessment every day shift, which included documentation of lung sounds, pulse and O2 saturation (measures the amount of oxygen in the blood). Continued review of Resident R1's clinical record revealed a nursing note dated July 4, 2025, at 10:20 a.m. by Licensed Nurse, Employee E3, that indicated upon attempt to administer medication, resident appears to be lethargic with very little verbal response. VS [vital signs] WNL [within normal limits] at this time. [...]

Inspectors wroteBased on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error for tone of five residents reviewed for medication administration. This deficiency was cited as past non-compliance. (Resident R1)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to provide a clean, comfortable, homelike environment for three of three resident floors observed. (First, Second, and Third floors)

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure medication regimen reviews were completed monthly by a licensed pharmacist and failed to ensure recommendations were reviewed timely by the physician for 13 of 33 resident records reviewed (Resident R20, R22, R24, R39, R73, R83, R91, R92, R110, R121, R127, R130, R132) Findings Include: Review of facility policy, Consultant Pharmacist Provider Requirements revised January 2021 indicates a system is established where the pharmacist recommendations regarding customers' (residents') drug therapy are communicated to those with authority and/or responsibility to implement and/or respond to the recommendations in an appropriate and timely fashion. [...]

Inspectors wroteBased on observation, review of facility policies and procedures and interviews with staff and residents, it was determined that the facility failed to implement an effective infection prevention and control progam related to enhanced barrier precautions, personal protective equipment and catheter care for three of three floors reviewed. (First, Second, and Third floors).

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for eight of ten months of antibiotic stewardship program data reviewed. (January 2024 through October 2024). Findings Include: Facility policy titled Antibiotic Stewardship (revised 2016), indicated that Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotics Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. [...]

Inspectors wroteBased on review of facility policies and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility.

Inspectors wroteBased on review of facility policy, observations, and interviews with staff, it was determined that the facility to provide sufficient space in relation to dining and recreation services for one of three floor reviwed. (third floor).

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to ensure that essential dining equipment in the dining room pantries and essential resident equipment was maintained in proper working order for three of three floors reviewed. (First, second, and third floors). Findings Include: Observation on October 23, 2024 of the dining room on the second floor at 12:02 p.m. revealed black mold under sink in the serving pantry area. Further observation revealed a cabinet was broken on bottom under steam table. Observation on October 23, 2024 of the dining room on the first floor at 12:10 p.m. revealed a dining room pantry area with an ice machine with an out of order not currently working. The hand sink was dirty with dirt residue in the sink and around the water handles and spout of the sink. Under the hand sink the cabinet had black mold. [...]

Inspectors wroteBased on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice of non-medical coverage (NOMNC) for three of three residents reviewed. (Resident R158, R314, R315). Findings Include: Review of facility beneficiary notice worksheet completed for the past six months revealed resident R315 was discharged home on September 11, 2024. There was no documentation showing that a Notice of Non-Medical Coverage (NOMNC) was reviewed with the resident prior to discharge. Review of facility beneficiary notice worksheet completed for the past six months revealed resident R314 was given a discharge date of June 2, 2024 but remained at the facility. Review of facility beneficiary notice worksheet completed for the past six months revealed resident R158 was given a discharge date of September 1, 2024 but remained at the facility. [...]

Inspectors wroteBased on review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to conduct required criminal background checks in a timely manner prior to employment for one of five new hired employees. (Employee E23) Findings Include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021 states, Policy Statement-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Further review of policy states, 4. [...]

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to notify the resident representative of the resident being transferred to the hospital twice for falls for one of 33 residents reviewed (Residents R24)

Inspectors wroteBased on interviews with residents and staff and observations, it was determined that the facility failed to provide activities that enhanced the resident's interactions for one of three floors observed. (Third floor) Findings Include: Observation made of several resident rooms on the Third floor on October 22, 2024 revealed the resident's did not have updated activities calendars posted in their rooms. All resident rooms observed on the Third floor had calendars posted that were from the month of September 2024. Interview with the Assistant Director of Activities Employee E11 on October 23, 2024 at 10:11 a.m. revealed that there was currently no calendar that was made for the month of October 2024. Employee E11 revealed that he had trouble creating the calendar therefore one was never made or given to residents throughout the facility. [...]

Inspectors wroteBased on review of clinical records, interview with staff and review of facility policy, it was determined that the facility did not ensure a resident received care in accordance with profession standards of practice when the facility failed to notify the physician for further instructions for a missed anti-anxiety medication for one resident of 33 clinical records reviewed (Resident R39).

Inspectors wroteBased on review of personnel files and interviews with staff, it was determined that the facility failed to ensure that nursing staff had specific competencies and skill sets necessary to care for residents' needs for four of four personnel files reviewed. (Employees E14, E15, E16, E17) Findings Include: Review of facility personnel files were made for competencies related to Medication Administration, Infection Control, Catheter Care, and Wound Care. Review of licensed nurse Employee E14's personnel file revealed that the employee was hired by the facility on May 6, 2021 as a licensed nurse. Review of licensed nurse Employee E15's personnel file revealed that the employee was hired by the facility on July 29, 2024 as a licensed nurse. Review of licensed nurse Employee E16's personnel file revealed that the employee was hired by the facility on June 5, 2024 as a licensed nurse. [...]

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not complete yearly performance review for nurse aides for two of four employees reviewed. (Employees E18 and E19) Findings Include: On October 23, 2024 at 11:00 a.m. with the facilities human resources director Employee E8 was interviewed and employee personnel records were requested for evidence of 12-hour trainings and yearly performance reviews for nurse aides. Four employee personnel records were requested including employee personnel record for nurse aides Employee E18 and E19. Interview on October 25, 2024 at 9:52 a.m. with the facilities human resources director Employee E8 revealed there were no completed yearly performance reviews completed for nurse aides Employee E18 and E19 even though they had been employed at the facility for over a year. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 33 residents reviewed (Resident R39 )

Inspectors wroteBased on observation and review of clinical records and facility policies, it was determined that the facility failed to ensure that residents' medication inlcuded the date that the medication was opened in accordance with currently accepted professional principles two of four residents' medication administration observed. (Resident R26 and R136).

Inspectors wroteBased on review of facility policy and interviews with staff, it was determined that the facility failed to maintain an effective, comprehensive, data-driven quality assurance and performance improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life as required.

Inspectors wroteBased on clinical record review, interview with residents and staff interview, it was determined that the facility failed to ensure residents received and were offered pneumococcal vaccines for one of 33 residents reviewed. (Resident R22) Findings Include: Interview held with Resident R22 on October 22, 2024 at 1:11 p.m. revealed the resident wanted to have the pneumococcal vaccine but had not yet been offered it by the facility. Review of the resident's clinical record revealed no information regarding the resident being educated on or offered the vaccination over the past year. On October 24, 2024 at 3:15 p.m. and interview with was held with the Director of Nursing Employee E2 and she confirmed that the facility had not yet offered pneumococcal vaccines to this resident or to any other resident in the facility. [...]

Inspectors wroteBased on staff interviews, the review of clinical records, and the review of facility documentation, it was determined that the facility failed to provide adequate staff supervision and monitoring to Resident R1 who was found to have a alcohol bottles in the resident's room. The facility's failure to provide adequate staff supervision and monitoring to Resident R1 with a history of storing and consuming alcohol resulted in Immediate Jeopardy to Resident R1 who sustained a fall, required transfer to the hospital and was diagnosed with a fracture hip for one of three residents reviewed. (Resident R1).

Inspectors wroteBased on staff and resident interviews and the review of facility documentation, it was determined that the facility failed to conduct a complete and through investigation for a resident's allegation of missing cigarettes and the facility failed to ensure that residents in the facility were protected from further potential abuse related to an allegation of an alleged perpetrator stealing money and jewelry for 1 out of 3 residents reviewed. (Resident R2)

Inspectors wroteBased on a review of clinical records, facility documentation, and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding a resident who was storing and consuming alcohol at the facility, sustained a fall, required transfer to the hospital and diangnosis of right hip fracture, which resulted in an Immediate Jeopardy situation for one out of three residents reviewed (Resident R1).

Inspectors wroteBased on observations, staff interviews and review of pest control logs, it was determined that the facility failed to ensure an effective pest control environment.

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not develop a comprehensive, person-centered care plan related to wound care for one of nine resident records reviewed (Resident R2).

Inspectors wroteBased on clinical record review and interview with staff and residents, it was determined that the facility did not ensure that wound care was completed appropriately to treat pressure ulcers for four of five residents with wounds reviewed (Residents R1, R2, R3, and R4).

Inspectors wroteBased on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that physician assessments were accurately completed and documented to reflect the actual condition of the residents for four of nine records reviewed (Residents R1, R2, R3, and R4).

Inspectors wroteBased on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that five of seven residents were receiving treatment and care in accordance with professional standards of practice as indicated in their comprehensive person-centered care plan. (Residents R1, R2, R3, R4, and R5)

Inspectors wroteBased on review of clinical records, facility documentation and interviews with staff, it was determined that the facility did not obtain, clarify and/or follow physican orders related to laboratory studies in a timely manner for one of four records reviewed (Resident R2).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the call bell alert system was in working order for one of three nursing units (first floor nursing unit).

Inspectors wroteBased on the review of clinical records and interview with staff, it was determined that the facility failed to notify the Office of the State Long- Term Care Ombudsman of facility initiated transfers and failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer for two of 32 residents reviewed. (Resident R91 and R71). Findings Include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R91 dated December 15, 2023, revealed that the resident was admitted to the facility on [DATE], and had a BIMS score of 10 which indicated that the cognitive status was moderately impaired. Review of nursing note for Resident R91 dates December 7, 2023, revealed that the resident experienced a change in condition related to abnormal vital signs. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 32 residents reviewed. (Resident R91 and R71)

Inspectors wroteBased on observations, clinical record reviews, review of facility policy and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plan related to hearing needs and behavioral needs for three of 33 residents reviewed. (Residents R7, R113, R10)

Inspectors wroteBased on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for two of two dialysis residents reviewed (Residents R138 and R141).

Inspectors wroteBased on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of 32 residents reviewed (Resident R63, and R73). Findings Include: Review of the undated Medication Regimen Review Policy revealed, The consultant pharmacist will review the drug regimen of all residents at least monthly and report any observed irregularities in drug use and other drug therapy recommendations to the director of nursing and attending physician. Further review revealed, The physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing, Resident R63 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar). [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater.

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to make certain that medications were stored at the proper temperature in one of two medication refrigerators reviewed.

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable and served at the proper temperature for five of eleven residents reviewed (Residents R5, R1, R3, R2 and R6).

Inspectors wroteBased on review of facility policy, observation, and interviews with staff, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and an interview with staff, it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on the review of facility Quality Assurance Performance Improvement program, Performance Improvement Program plan, facility documentation, and interview with staff, it was determined that the facility failed to demonstrate and maintain an effective quality improvement program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators.

Inspectors wroteBased on observations, interviews, and a review of facility documentation, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on a review of facility documentation and staff interview, it was determined that the facility failed to ensure its nurse aide staff was receiving in-service training to be proficient and competent and that the training be no less that 12 hours annually for six of six nurse aide staff training information reviewed (E10, E11, E12, E13, E22 & E23). Findings Include: Review of the nurse aide annual training information provided during the survey revealed that there were no training logs to review for nurse aides E10, E22 and E23. Review of the nurse aide annual training information provided during the survey revealed that nurse aides E11, E12 and E13 training logs did not contain any training since January 2023, and did not meet the twelve hours of annual training requirement. An interview with the Director of Nursing on January 12, 2024, at 9:15 a.m. [...]

Inspectors wroteBased on a group interview, observations and interviews with staff, it was determined that the facility failed to display proper contact information for the State Survey Agency, including the Hotline number on all three nursing floors (First, Second and Third Floors).

Inspectors wroteBased on observations, interview with residents and staff, it was determined that the facility did not ensure that most recent survey results were accessible to residents on three of three nursing units observed (First, Second and Third Floors).

Inspectors wroteBased on observations and resident interviews, it was determined that the facility failed to maintain one of three nursing floors in a clean, comfortable, and homelike condition. (Third floor)

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of 7 residents reviewed related to PASRR assessments (Resident R34).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to revise a resident's care plan related to the discontinuation of eteral feeding for one of 32 residents reviewed (Resident R128).

Inspectors wroteBased on observation, review of clinical records, review of facility policy, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for one of 32 residents reviewed. (Residents R108)

Inspectors wroteBased on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order related to medications administration and hospice services for two of 33 residents reviewed (Resident R90 and R128). Findings Include: Review of clinical record for Resident R90 revealed that the resident was admitted to the facility on [DATE], with diagnosesof deep vein thrombosis (DVT, A blood clot in a deep vein, usually in the legs), obstructive uropathy (disorder of the urinary tract), and glaucoma (a group of eye conditions that damage the optic nerve). Review of the physician approved medication list revealed the following medications were approved and were to be provided to resident R90 during his stay in the facility: [...]

Inspectors wroteBased on observations, review of facility policies, review of clinical records and interviews with resident representatives and staff, it was determined that the facility failed to obtain an appointment with a hearing specialist for one of 32 residents reviewed (Resident R7).

Inspectors wroteBased on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that weights were monitored for one of 37 residents reviewed (Resident R8)

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to ensure that licensed nursing staff had the proper competencies including catheter care, tube feeding care and post dialysis care for four of four licensed nurse training records reviewed (E14, E15, E16 & E17).

Inspectors wroteBased on review of facility policy, observation, review of clinical record, interview with staff and residents it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for two of 37 residents reviewed. (Resident R18 and Resident R19)

Inspectors wroteBased on review of facility documentation, facility policies, and staff interviews, it was determined that the facility failed to implement an effective antibiotic stewardship program that includes a system to effectively monitor infections and antibiotic usage.

Inspectors wroteBased on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain essential equipment in safe operating condition. Findings Include: A tour of the first floor of the facility was conducted on January 9, 2024, and January 11, 2024. On January 9, 2024, at 12:16 p.m., and on January 11, 2024, at 1:19 p.m., observations in room [ROOM NUMBER], Bed B, revealed the side enabler of resident bed was unstable and unsteady, and the air-mattress was not blowing up.

Inspectors wroteBased on observation and resident and staff interviews, it was determined that the facility failed to assure all equipment was effective to provide full visual privacy for each resident in seven of 13 resident rooms observed. (Rooms 235, 226, 233, 228, 236, 238, 232)

Inspectors wroteBased on observation, staff interviews and review of facility policy, it was determined that the facility failed to ensure that linens were handled by a professional laundering services in order to meet health care industry laundry standards.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment for two of three nursing units and in the laundry room. (First floor, Second floor and Laundry room)

Inspectors wroteBased on observation, interview with residents and staff, and review of facility policy, it was determined that the facility failed to ensure the resident call bell alert systems were functional properly for three residents on two nursing units. (Resident R3, Resident R4, Resident R5) Finds include: Review of facility policy titled Answering the call light dated March 2021 revealed the purpose of this procedure is to ensure a timely response to the resident's requests and needs. Further review of this policy states to be sure the call light is plugged in and functioning at all times. Observation during tour of the facility on December 5, 2023 at 9:00 a.m. revealed that Residents R3 and R4, and R5 had nonfunctioning call bells. Interview with Housekeeper, Employee E3 at time of interview confirmed that these call bells did not function properly. 28 Pa. [...]

Inspectors wroteBased on clinical record review, observation, staff and resident interview, and review of facility policy, it was determined that the facility failed to maintain proper infection control practices to prevent the potential spread of infection for two of ten residents reviewed regarding isolation practices.

Inspectors wroteBased on clinical record review and interview with staff and residents, it was determined that the facility failed to ensure completed documentation related to catheter care and emptying of catheter drainage bag for one of one resident reviewed with a urinary catheter (Resident R1).