Fleshers Fairview Health Care

Inspectors wroteBased on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to consult with the physician about a new pressure ulcer that developed on 08/22/25 on Resident #8's right heel. The pressure ulcer was observed 08/22/25 with no notification to the physician until 09/09/25 when the pressure ulcer to Resident #8's right heel was assessed and documented as an unstageable wound to the right heel with black eschar (dry, black, or brown crust that forms on the surface of wounds) with foul odor and measuring 3.5 centimeters (cm) by 3.5 cm. The facility also failed to consult the physician when Resident #2's diabetic foot ulcer was identified on 09/10/25. In addition, the facility also failed to consult the physician when Resident #16's stage II pressure ulcer was identified on 08/31/25 and when Resident #29 experienced significant weight loss. [...]

Inspectors wroteBased on record review, observations, and interviews with staff, Wound Nurse Practitioner, Nurse Practitioner (NP), and Medical Diractor the facility failed to provide skin assessments, failed to identify a new wound on the heel at the onset, and failed to ensure necessary medical treatment when positive culture and sensitivity results were available Resident #2. This delayed the treatment for an infected wound. This was for 1 of 2 residents (Resident #2) reviewed for quality of care.

Inspectors wroteBased on observations, record reviews, interviews with the Wound Care Nurse Practitioner, Medical Director and staff, the facility failed to obtain treatment orders for two (2) pressures ulcers (Resident #8 and Resident #16) when first identified resulting in numerous days that the pressure ulcers went without treatment and worsening to unstageable for Resident #8 and a stage 2 for Resident #16. Resident #8's pressure ulcer was first identified on 08/22/25 as a red open area but an assessment or treatment was not documented. The pressure ulcer was later identified on 09/04/25 and treatment was initiated but no assessment was documented. The pressure ulcer was assessed and documented on 09/09/25 as unstageable wound to the right heel with black eschar (dry, black, or brown crust that forms on the surface of wounds) with foul odor and measuring 3.5 centimeters (cm) by 3.5 cm. [...]

Inspectors wroteBased on observations, record review, and staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to provide supervision to prevent a fall with injury and failed to implement effective fall interventions for a resident (Resident #11) who had repeated falls. Resident #11 experienced 12 falls from 1/22/25 to 7/24/25. On 7/24/25 Resident #11 sustained a left ankle fracture when she was left unsupervised in the bathroom and fell. Additionally, the facility failed to supervise a cognitively impaired resident (Resident #10) who wandered and exited the facility unsupervised on two separate occasions. This deficient practice occurred for 2 of 3 residents reviewed for supervision to prevent accidents.

Inspectors wroteBased on observations, record reviews and resident and staff interviews, the facility failed to maintain sufficient staff to provide activities of daily living (ADL) care for dependent residents, to obtain treatment orders for residents with pressure ulcers when the pressure ulcers were first identified, to routinely assess a resident for being at risk of a pressure ulcer, to implement measures to prevent a resident from developing a pressure ulcer and then failed to provide an ongoing assessment, treatment, and necessary medical care for a resident's diabetic and pressure ulcer. Additionally, the facility failed to complete accurate head to toe assessments to identify new or existing pressure ulcers. This was for 5 of 9 residents reviewed for sufficient staffing (Resident #2, Resident #8, Resident #11, Resident #6 and Resident #28).

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during the Resident Council meetings for 8 of 12 months reviewed (November 2024, December 2024, January 2025, March 2025, April 2025, May 2025, June 2026, and July 2025).

Inspectors wroteBased on record review, and resident, staff, and Resident Representative interviews, the facility failed to allow residents/representatives the opportunity to formulate an advance directive. Additionally, the facility failed to provide residents/representatives with written information regarding advance directives and the right to accept or refuse medical or surgical treatment for 2 of 4 residents reviewed for advance directives (Resident #11 and Resident #3).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to provide activity of daily living (ADL) care for dependent residents when Resident #28 and Resident #11 did not receive showers. This deficient practice affected 2 of 4 residents reviewed for ADL care (Resident #28 and Resident #11).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to serve a meal to all residents sitting at the same dining table, prior to serving other tables (Resident #42). Additionally, the facility failed to provide feeding assistance while sitting at eye level (Resident #30). This was for 2 of 22 residents reviewed for dignity (Residents #42 and #30). A reasonable person concept was utilized for Resident #42 and would want to have her meal served along with other residents at the dining table.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to protect residents' personal health information by leaving confidential medical information unattended, visible and accessible to others on top of the medication cart for 1of 4 medication carts observed for privacy and confidentiality (500 hall).

Inspectors wroteBased on observation, record review, and staff and Medical Director interviews, the facility failed to protect a resident's right to be free from physical abuse when an employee (Staff #13) slapped Resident #44 on the hand with an open hand during care. This deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #44).

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy and procedure in the areas of prevention, protection, reporting, and investigating. The facility failed to immediately implement protection and report abuse when Nurse Aide (NA) #12 witnessed Staff #13 grab both of Resident #44's wrists followed by slapping the resident's hand during care on 5/28/25 between 8:00 PM and 9:00 PM and did not immediately intervene and report the abuse to administration. Staff #13 continued to provide resident care to Resident #44 and worked on the floor for the remainder of her shift. On 5/28/25 at approximately 11:00 PM NA #12 reported the incident to Nurse #13 and Nurse #7 and the administration was not notified of the incident until the following morning (5/29/25) when Nurse #13 reported the allegation to the Director of Nursing (DON). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Preadmission Screening and Resident Review (PASRR) Level II (Resident #4 and Resident #2) and Pressure Wound (Resident #2) for 2 of 19 residents reviewed for MDS accuracy (Resident #2 and Resident #4).

Inspectors wroteBased on record reviews, observation, and staff interviews, the facility failed to revise the care plan in the area of pressure ulcers (Resident #8) for 1 of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, record review, and staff, and Medical Director interviews, the facility failed to act on the Registered Dietitian's (RD) recommendation of 8/31/25 to reweigh a resident (Resident #29) after a monthly weight triggered a significant weight change. The diet order was revised to add more calories, and the volume of the nutritional supplement was increased as recommended by the RD. The facility failed to reweigh Resident #29 until 9/3/25 and then staff did not document the weight or report it to nursing management until 9/18/25. The reweight confirmed a significant weight loss. During meal observation on 9/19/25, Resident #29 did not consume any food on her own and staff did not provide any cues or encouragement to eat. The interdisciplinary team did not discuss Resident #29's weight loss or lack of eating in the clinical meeting, nor was it reported to the physician. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to clean oxygen concentrator filters (Resident #1 and Resident #2) and provide oxygen in use signage on resident room entrances (Resident #1, Resident #2, and Resident #9) for 3 of 3 residents reviewed for respiratory care (Resident #1 and Resident #2, Resident #9). In addition, the facility failed to secure an oxygen tank stored upright in a resident's room (Resident #1) and failed to secure an oxygen tank while being transported for 1 of 1 staff member observed carrying an oxygen tank (Nurse Aide #2). Findings Included:1a. Resident #1 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Resident #1 had active physician order dated 8/7/25 for oxygen via nasal cannula at 2 liters per minute every shift. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide staff that met minimum competency requirements when they employed a staff member to work in the capacity of a nurse aide (NA) and were assigned NA tasks who had not completed a state-approved nurse aide training program, certification exam, or competency evaluation prior to providing direct care to residents. This deficient practice occurred for 1 of 8 staff reviewed for minimum competency requirements (Staff #17).

Inspectors wroteBased on manufacturer guidelines, observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors from 1 of 3 medication carts (200 Hall) and failed to label and store inhalation breathing solutions (Budesonide, Albuterol Sulfate, DuoNeb) according to manufacturers' guidelines for 2 of 3 medication carts (200 and 500 hall) reviewed for medication storage.

Inspectors wroteBased on record review, and staff, Wound Provider, Nurse Practitioner, and Medical Director interviews, the facility failed to notify the Wound Provider of a positive wound culture and sensitivity lab result when the results were received. This resulted in a delay of antibiotic treatment for 1 of 1 resident reviewed for notifying a physician of laboratory results (Resident #2). Findings Included:Resident #2 was admitted on [DATE] with diagnoses of vascular dementia and hemiparesis (weakness of a limb) and hemiplegia (side of body paralyzed) of left side following a stroke. A progress note written by the Wound Nurse dated 9/10/25 at 2:05 PM read she found an open area on Resident #2's left heel. The note read the open area was unstageable and measured 2 centimeters (cm) x 1.5 (cm). On 9/11/25 the Wound Provider evaluated the left heel dorsal wound. The Wound Provider treatment note read; [...]

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to follow their Hand Hygiene and Enhanced Barrier Precautions (EBP) policy and procedures when the Wound Nurse did not don a gown, doff her gloves, perform hand hygiene and don clean gloves after removing the soiled dressing and after cleansing the wound and before applying the new dressing during wound care to Resident #8. The Wound Nurse also did not don a gown, use hand hygiene after doffing gloves after removing soiled dressing and before donning clean gloves, and did not doff gloves and use hand hygiene after cleansing the wound and before applying the new dressing during wound care to Resident #2 for 1 of 7 staff observed for infection control practices (Wound Nurse).

Inspectors wroteBased on observations and staff interviews, the facility failed to keep essential equipment clean and in safe operating order for 2 of 2 dryers (dryer #1 and dryer #2) observed for safe operating conditions.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the Nurse Staffing Information was posted in a prominent place that was readily accessible to residents, staff and visitors. The facility also failed to ensure the posted Nurse Staffing Information accurately reflected the facility census and staffing for 4 of 4 days (09/16/25, 09/17/25, 09/18/25 and 09/19/25).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the residents' clothing was stored in a sanitary manner in the laundry room inside the facility and failed to ensure the laundry room outside the facility was free of dust. Additionally, the facility failed to ensure a pill crusher's surfaces were free from what appeared to be a dried light brown liquid substance on the end of the pill crusher and had dark brown particles embedded in the dried liquid. The deficient practice affected 2 of 2 laundry rooms and 1 of 4 pill crushers (100 hall) reviewed for safe, clean and homelike environment.

Inspectors wroteBased on record review, interviews with the Medical Director (MD), resident and staff, the facility failed to provide care in a safe manner when a resident fell from her bed during personal care. Resident #4 fell off her bed striking a chair positioned next to the bed and subsequently fell to the floor that resulted in severe acute pain that required STAT (now) morphine and a fractured right femur. The resident was hospitalized for surgical repair of the fractured femur. This was for 1 of 5 residents reviewed for the prevention of accidents (Resident #4). Findings Included: Resident # 4 was admitted to the facility on [DATE] with diagnosis that included functional quadriplegia, dementia, and traumatic brain injury. [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to provide competent nursing staff when 5 of 6 nursing staff (Nurse #2, Nurse #3, Nurse #4, Nurse #5, and the Weekend Nurse Supervisor) did not know the process for glucometer disinfection.

Inspectors wroteBased on observations, staff and resident interviews, and record review the facility failed to secure antifungal powder for 1 of 1 resident (Resident #4) observed with prescription medicated powder at bedside. In addition, the facility failed to lock an unattended medication cart 1 of 4 medication carts (600-hall medication cart) observed for medication storage.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services to 1 of 3 residents (Resident #45) reviewed for beneficiary notification.

Inspectors wroteBased on record review, staff and pharmacy technician interviews the facility failed to obtain an ordered antibiotic from the pharmacy which resulted in 2 missed doses of an antibiotic. This deficient practice occurred for 1 of 1 resident reviewed for pharmacy services (Resident #35).

Inspectors wroteBased on record review, staff and Physician interviews the facility failed to administer an antibiotic as ordered for 1 of 1 resident reviewed for significant medication errors (Resident #35). Resident #35 missed two doses of an antibiotic.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to establish and implement a policy and procedure for glucometer disinfection when Nurse #2 and Nurse #3 failed to disinfect a resident (Resident #21) glucometer after performing a capillary blood glucose test. This deficient practice occurred for 1 of 1 resident (Resident #21) reviewed for infection prevention and control.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the privacy of a resident's record when the computer screen was left open with resident information exposed during 2 observations for 1 of 4 medication carts observed (600-hall medication cart).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean walk-in refrigerator from an accumulation of a thick, clumpy grayish matter on the circulatory fan cover, around the light, and electrical cords of 1 of 1 walk-in refrigerators. The facility failed to maintain a clean walk-in freezer from an accumulation of a thick, clumpy, grayish matter around the light fixture in 1 of 1 walk-In freezers. Additionally, the facility failed to maintain a clean air vent and surrounding ceiling from accumulation of a grayish, thick, clumpy buildup. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review and interviews with staff, the facility failed to request a Preadmission Screening and Resident Review (PASRR) level II screen evaluation for a resident with a new mental health diagnosis for 1 of 3 residents reviewed for PASRR (Resident #34).

Inspectors wroteBased on record review and interviews with the resident, staff, and Medical Director (MD), the facility failed to develop a care plan for pain for 1 of 2 residents reviewed for pain (Resident #24).

Inspectors wroteBased on record review, observations, and interviews with staff the facility failed to maintain oral hygiene for a resident dependent on staff for brushing teeth and denture care for 1 of 3 residents reviewed for activities of daily living (Resident #26).

Inspectors wroteBased on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to monitor the cholesterol level for 1 of 5 residents reviewed for unnecessary medications (Residents #33).

Inspectors wroteBased on record review and interviews with the resident, staff, and Medical Director (MD), the facility failed to implement labs as ordered for 1 of 5 residents reviewed for unnecessary medications (Residents #33).

Inspectors wroteBased on observations, record review and resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 08/05/21 recertification survey. This was for 1 recited deficiency on the current recertification and complaint investigation survey of 05/18/23 in the area of development/implementation of comprehensive care plan (F 656) that was cited on 08/05/21 recertification survey. The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program.