Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairview Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke, HTN, and depression had a POA document on file naming one family member as attorney-in-fact and another as successor, but the facility continued to treat the successor as the primary contact based on admission paperwork. When the NOMNC was issued, staff notified and obtained a signature from the successor contact, informing that person of the last Medicare coverage day and appeal process, while the named POA reported not being informed of the coverage termination or appeals. Interviews with the administrator, Medicare Account Technician, and social services designee showed that staff relied on the original emergency contact listing and did not update the first contact to the POA after the POA paperwork was uploaded, leading to failure to notify the correct representative.
A resident with severe cognitive impairment, COPD, and CHF was ordered Ipratropium-Albuterol nebulizer treatments and was not assessed to self-administer. During observation, the resident removed her own nebulizer mask because staff had not returned to take it off, and an RN later stated he typically started the treatment and returned 10 to 15 minutes later rather than staying in the room for the full treatment. The NM, ADON, and DON stated staff were expected to remain with the resident for the duration of the nebulizer treatment.
Failure to Include Respiratory Needs in Care Plan: A resident with severe cognitive impairment, COPD, and CHF did not have a respiratory-specific care plan, and the comprehensive care plan did not include the resident’s preference for staff to remove the nebulizer mask after treatments. The resident stated staff often did not return to remove the mask, leaving the resident to take it off herself. Staff and the DON confirmed the resident lacked a respiratory care plan despite ordered nebulizer treatments.
An LPN used the same glucometer for two diabetic residents' blood sugar checks and cleaned it with wipes that were not appropriate for disinfecting equipment. The LPN stated the same glucometer was used for all residents, while the infection preventionist said each resident is assigned their own glucometer and that proper disinfectant wipes and wet time are required when a meter is shared.
A resident developed a stage 3 pressure ulcer due to the facility's failure to assess and manage a blister that ruptured and worsened. The facility did not notify the physician or update the care plan, leading to the wound's deterioration. Staff interviews revealed communication breakdowns and inadequate wound management procedures.
The facility failed to properly label and store medications, including insulin pens and tuberculin solution, and did not remove expired medications from stock. An LPN was observed using an insulin pen without an opened date, and several expired medications were found in the medication cabinet. The DON acknowledged the need for monthly checks to prevent such issues.
A resident with mild cognitive impairment and multiple diagnoses, including COPD and asthma, was observed self-administering a nebulizer treatment without proper assessment. Staff set up the nebulizer and left the resident alone, contrary to facility policy, which requires an assessment and care plan for self-administration. Interviews confirmed the resident was not assessed for this ability.
A facility failed to ensure residents with swallowing difficulties were assisted by qualified individuals. An activity aide fed a resident with dysphagia a mechanical soft diet, despite the need for a pureed diet. The resident's care plan required staff assistance to prevent aspiration, but unlicensed staff were allowed to feed residents, contrary to speech therapy recommendations and federal guidelines.
A resident with Alzheimer's and a history of falls had a care plan that was not updated promptly after a fall incident, leading to confusion among staff about the correct transfer method. The interdisciplinary team had decided on a new intervention, but it was not reflected in the care plan until weeks later, resulting in conflicting instructions. Staff interviews highlighted the expectation for timely updates and review of care sheets, which was not met.
The facility failed to assess and monitor bruises in three residents, including one with impaired cognition and another on anticoagulant therapy. Despite multiple observations of bruising, the facility did not document comprehensive assessments or monitoring of these injuries. The DON acknowledged the lack of proper assessment and monitoring in the residents' medical records.
A resident with chronic hyponatremia secondary to SIADH did not receive prescribed Urea doses due to pharmacy delays, and the facility failed to report this as a medication error. The resident's POA and physician were not notified of the omission, and the facility's policy lacked clear guidelines for handling such errors.
The facility failed to timely dispose of over 2000 discontinued medications, including narcotics, which were improperly stored and mixed with active medications. Staff interviews revealed inconsistencies in following the medication disposal process, with narcotics remaining in the medication cart until removal by the DON or ADON. The facility's policy required controlled medication disposal by two licensed nurses, but this was not adhered to, resulting in a significant deficiency.
A resident with a history of urinary complications experienced discomfort and bleeding due to improper placement of an indwelling urinary catheter by a nurse, who failed to advance the catheter beyond the point of urine return. This led to the resident's transfer to the hospital, where a CT scan revealed the catheter was incorrectly positioned in the posterior urethra. The facility's policy was not followed, and improper handling of a used urinary drainage bag was also noted.
Failure to Notify Designated POA of Medicare Coverage Termination
Penalty
Summary
The facility failed to properly recognize and notify the appropriate resident representative regarding the end of Medicare coverage and related appeal rights for one resident. The resident, who was cognitively intact and had a history of stroke, hypertension, and depression, was admitted with a consent form listing one family member (FM-B) as the first emergency contact and guarantor, and another family member (FM-A) as the second emergency contact. The consent form was signed by FM-B. A statutory short form power of attorney (POA) document, dated several years earlier, identified FM-A as the attorney-in-fact and FM-B only as the successor attorney-in-fact, to act if the named attorney-in-fact could not serve. This POA document was uploaded into the resident’s medical record after admission. When the Notice of Medicare Non-Coverage (NOMNC) was issued, it stated the last day of Medicare coverage and included a handwritten note that FM-B was updated by phone about the last coverage day, the appeal process, and the email address to which the document was sent; the NOMNC was signed by FM-B. FM-A later reported she had provided the POA paperwork to the facility before the NOMNC was issued and that she was never informed of the end of Medicare coverage or the appeals process. The administrator stated the NOMNC was issued to FM-B because she had signed the admission papers and was indicated as the first contact, and reported being unaware that POA paperwork had been provided at that time. The Medicare Account Technician confirmed sending the NOMNC to FM-B based on her status as first contact and did not look for POA documentation, expecting social services to update the chart if POA paperwork was received. The social services designee stated that although the POA paperwork for this resident had been uploaded, the first contact had not been changed to the POA, resulting in the failure to notify the designated attorney-in-fact.
Nebulizer Treatment Not Supervised for Resident Unable to Self-Administer
Penalty
Summary
The facility failed to ensure a medication was administered safely for one resident who had been assessed as unable to safely self-administer medications. The resident had severe cognitive impairment on the annual MDS and required assistance with dressing, footwear, and eating. Her diagnoses included COPD and CHF. Her orders included Ipratropium-Albuterol inhalation three times per day, with the instruction that she does not self-administer the nebulizer. During observation and interview, the resident stated staff had not returned to remove her nebulizer mask, so she removed it herself because she did not know whether the treatment was complete and felt the mask had been on too long. Later observations showed an RN entering the room, applying the nebulizer treatment, and then leaving, and then returning later to stop the nebulizer, remove the equipment, and rinse it out. The RN stated he started the treatment and normally returned 10 to 15 minutes later to check whether the liquid was gone, and confirmed the resident was not assessed to self-administer. The NM, ADON, and DON each stated staff were expected to remain with the resident for the duration of the nebulizer treatment because she was cognitively impaired and did not have a SAM assessment.
Failure to Include Respiratory Needs in Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with severe cognitive impairment who had diagnoses of COPD and CHF. The annual MDS indicated the resident required assistance with dressing, footwear, and eating. Although the resident was ordered Ipratropium-Albuterol inhalation treatments three times daily and did not self-administer nebulizer treatments, the care plan did not include a respiratory care plan and did not include the resident’s preference for staff to remove the nebulizer mask after treatments. During observations, the resident stated that when nebulizer treatments were complete, staff did not return to remove the mask and she had to take it off herself, which bothered her. The nebulizer mask was observed sitting on the resident’s bedside table and later in her wheelchair. Staff were observed applying the nebulizer, and after the treatment was complete, staff did not immediately return to remove the mask; later, an RN entered the room, stopped the nebulizer, unhooked the mask and equipment, and rinsed it. The RN stated staff sometimes got busy and did not return right away to remove the mask, and confirmed the resident did not have a respiratory-specific care plan. The DON confirmed the resident did not have a respiratory care plan and stated she would expect a resident with CHF and COPD to have one.
Improper Glucometer Disinfection Between Resident Blood Sugar Checks
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for two residents who received blood sugar checks using the same glucometer. R9 and R45 were both identified in their MDS assessments as diabetic, and both had orders for blood sugar monitoring four times a day. During observation, an LPN took a glucometer case from the medication cart into R45's room, checked R45's blood sugar, returned the glucometer to the case, and placed the case back in the cart. The LPN stated residents were supposed to have their own machine, but they were not marked, and also stated the same glucometer was used for all residents and was wiped off with green wipes. Later, the same LPN wiped the glucometer with a green package of Medline FitRight wet wipes and used it to check R9's blood sugar. The package of wipes did not have an EPA registration number. The LPN stated alcohol wipes were used to clean the machine between residents, while the infection preventionist stated each resident is assigned their own glucometer but staff should use the proper disinfectant wipe and correct wet time if the same glucometer is used for multiple residents. The infection preventionist identified Oxivir wipes or blue top wipes as the facility's disinfectants and stated the FitRight wipes were for incontinence care and not appropriate for disinfecting equipment. The glucometer user manual required disinfection between patient uses with a CaviWipe or other EPA-registered disinfecting wipe, and the facility policy dated December 2013 directed staff to wipe the glucometer with a Clorox wipe after each use.
Failure to Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to comprehensively assess and manage a pressure ulcer for a resident who entered the facility without any pressure ulcers. The resident, who had a diagnosis of a right femur fracture and was dependent on staff for all care, developed a stage 3 pressure ulcer. Initially, a fluid-filled blister was noted on the resident's left upper thigh/buttock region, believed to be caused by a tight personal wheelchair and difficulty with a mechanical lift sling. Despite the blister rupturing and the wound worsening, the facility did not notify the physician or update the care plan to address the wound. The resident's wound was not appropriately staged or assessed after the blister ruptured, and the care plan was not revised to include interventions to prevent further deterioration. The facility's staff failed to communicate the changes in the wound to the physician, and the wound continued to worsen without appropriate treatment. The wound eventually measured 8.0 cm x 5.0 cm and was determined to be at least a stage 3 pressure ulcer with slough and eschar present. Interviews with facility staff revealed a breakdown in communication and a lack of proper wound management procedures. Staff members admitted to not notifying the physician of the wound changes and not updating the care plan. The facility's wound management program was not effectively implemented, leading to the resident's wound worsening without appropriate interventions or physician involvement.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically insulin pens and tuberculin solution, as well as the removal of expired medications. During an observation, an LPN was preparing an insulin pen for a resident without an opened date on the pen, which is against the manufacturer's guidelines. The LPN acknowledged the missing date and disposed of the pen, retrieving a new one to continue the preparation. Additionally, the facility's practice of requiring two nurses to verify insulin was noted as a measure to prevent medication errors. Further investigation into the medication storage revealed that a bottle of tuberculin solution in the refrigerator was nearly empty and lacked an opened date. The review also uncovered several expired medications in the stock medication cabinet, including senna plus, stool softeners, iron tablets, nasal sprays, and vitamin D. The DON admitted that monthly checks should be conducted to prevent expired medications from being available, as per the facility's policy on medication administration and storage.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to assess a resident, identified as R31, for their ability to self-administer nebulizer treatments. R31, who was mildly cognitively impaired with a diagnosis of dementia, heart failure, COPD, and asthma, was observed self-administering a nebulizer treatment without proper assessment. The resident's care plan indicated a need for assistance with activities of daily living and noted the resident's forgetfulness, requiring staff to anticipate their needs. Despite this, the registered nurse and trained medication aide set up the nebulizer treatment and left the resident alone, contrary to the facility's policy. Interviews with staff, including an LPN and the Director of Nursing, confirmed that R31 was not assessed for self-administration of medication. The facility's policy required an order for self-administration, a completed assessment, and an established care plan, none of which were in place for R31. The Director of Nursing verified that R31 was not assessed to be left alone with the nebulizer running, indicating a failure to adhere to the facility's policy on self-administration of medication.
Inadequate Supervision of Feeding for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that residents with difficulty swallowing were assisted with meals by qualified individuals. During an observation, an activity aide was seen feeding a resident who was supposed to be on a pureed diet but was given a mechanical soft diet at the family's request. The resident, who had a history of stroke, dysphagia, and left-sided hemiplegia, was at risk of aspiration and required staff assistance during meals. Despite these needs, the facility allowed unlicensed staff to feed the resident, contrary to the recommendations by speech therapy and the facility's own policies. The resident's care plan and shared risk agreement indicated the need for a mechanically soft diet with honey thick liquids, acknowledging the risks of aspiration and pneumonia. However, the facility's director of nursing confirmed that unlicensed staff were permitted to feed residents, including those with swallowing concerns. The medical director was unaware that staff had not reassessed who could feed the resident, highlighting a lack of communication and oversight. The facility's training program for feeding assistants did not align with federal requirements, which state that feeding assistants should only assist residents without complicated feeding problems, such as difficulty swallowing.
Failure to Update Care Plan Leads to Confusion in Resident Care
Penalty
Summary
The facility failed to revise the care plan for a resident after changes were made to fall prevention measures. The resident, who has Alzheimer's disease and a history of repeated falls, experienced an unwitnessed fall resulting in injuries. The interdisciplinary team reviewed the incident and decided on a new intervention to address the resident's restlessness in bed. However, this intervention was not updated in the care plan until several weeks later, leading to confusion among staff regarding the appropriate transfer method for the resident. During an observation, a nursing assistant attempted to use an incorrect transfer method due to outdated information on the care sheet. The assistant was unaware of the change to a total mechanical lift transfer, as the care plan had conflicting instructions. Interviews with the RN and DON revealed that care plans should be updated promptly, and staff are expected to review care sheets before their shifts. The facility's policy requires care plans to be revised as the resident's status changes, which was not adhered to in this case.
Failure to Monitor and Assess Bruises in Residents
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin injuries, specifically bruises, for three residents. For Resident 1, the facility did not document a comprehensive assessment of the bruises, including their location, size, and any associated pain. Despite multiple observations of bruising on different parts of Resident 1's body, the records lacked detailed monitoring and assessment of these injuries over time. The facility's documentation did not include a comprehensive skin assessment and monitoring of the bruises identified on various dates. Resident 2, who had a severely impaired cognition and was on anticoagulant therapy, was found with a bruise on the dorsal right hand. The facility's records did not include a comprehensive skin assessment and monitoring of this bruise. The care plan for Resident 2 included interventions to observe for signs and symptoms of adverse side effects related to anticoagulant medication, but the facility failed to document a thorough assessment and monitoring of the bruise. Resident 3, diagnosed with Alzheimer's disease and dementia, was found with bruising around the wrists and forearms. The facility's records lacked measurements and comprehensive monitoring of these bruises. Despite the resident's high risk of bruising due to anticoagulant therapy, the facility did not conduct a comprehensive skin assessment and monitoring of the bruises identified on multiple occasions. The Director of Nursing acknowledged that the facility was not currently assessing or monitoring for healing, and no comprehensive skin assessments were documented in the residents' medical records.
Failure to Administer Prescribed Medication for Hyponatremia
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident diagnosed with chronic hyponatremia secondary to Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The resident, who had a history of chronic kidney disease and hypoosmolality, was prescribed sodium chloride tablets and Urea to manage her low sodium levels. However, upon returning from a hospital stay, the resident did not receive the prescribed Urea doses on two consecutive days due to the medication not being available from the pharmacy. The facility's documentation did not indicate that the resident's Power of Attorney (POA) or physician was notified of the omitted doses. Interviews with facility staff revealed that the omission was not reported as a medication error, and no medication error form was filled out. The facility's policy on medication errors did not clearly define the process for handling such errors, including notifying the medical provider and family. The resident's sodium levels were critically low, prompting hospitalization, and upon discharge, the resident required close monitoring and an adjusted medication regimen. Despite the critical nature of the resident's condition, the facility's failure to administer the prescribed medication and lack of communication with the medical provider and family constituted a significant medication error.
Failure to Timely Dispose of Discontinued Medications
Penalty
Summary
The facility failed to appropriately and timely dispose of 95 prescribed medications, totaling over 2000 pills, that had been discontinued. These medications were observed in the medication room, mixed with active medications, and included narcotics that were not properly segregated. During an observation and interview, it was noted that the medications were stored in bubble packs, vials, and ziplocked bags, and were not disposed of in a timely manner, leading to potential diversion risks. Interviews with the nursing staff revealed that the process for medication disposal was not consistently followed. LPN-A stated that narcotics were kept in the medication cart until the DON or ADON removed them, and that nurses verbally informed the DON or ADON of medications needing destruction. RN-A mentioned that narcotic medications stayed in the cart until they could be destroyed by two nurses, and the DON was responsible for tracking medication disposition. The DON acknowledged the complexity of the medication return policy and confirmed oversight of the destruction and return process. The facility's Medication Administration policy required controlled medication disposal to be done by two licensed nurses and co-signed in the Narcotics Log Book. However, the facility did not adhere to this policy, as evidenced by the large quantity of medications that were not disposed of in a timely manner. The pharmacy manager confirmed that the pharmacy would accept returns within 30 days if the medication was the full quantity dispensed, but controlled medications were not accepted for return. The facility had a MedSafe box for destroyed medications, but the process was not effectively managed, leading to the observed deficiency.
Improper Catheter Placement Leads to Resident Discomfort and Hospitalization
Penalty
Summary
The facility failed to correctly place an indwelling urinary catheter in a resident, leading to discomfort, bleeding, and the need for emergent medical services. The resident, who had a history of urinary tract infections, chronic kidney disease, and other urinary complications, required maximum assistance with toileting hygiene and had an indwelling urinary catheter. The care plan included specific interventions to prevent complications, such as changing the catheter as ordered and maintaining a closed drainage system. On a particular day, a registered nurse encountered difficulties flushing the resident's catheter and replaced it with a new one. However, the nurse did not advance the catheter beyond the point of urine return, which is against the facility's policy. This resulted in bright red blood in the catheter, and despite attempts to resolve the issue by flushing with normal saline, the resident was transferred to the hospital. A CT scan at the hospital revealed that the catheter had been placed in the posterior urethra, causing hematuria and leading to further complications. Interviews with staff revealed that the nurse believed the catheter was correctly placed due to urine return, but did not follow the policy of advancing the catheter further. Additionally, the clinical manager noted improper handling of a used urinary drainage bag, which was not disposed of or cleaned properly. The director of nursing confirmed the expectation for staff to follow the facility's catheter placement policy, which includes advancing the catheter beyond the point of urine return and ensuring proper disposal of used equipment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dodge Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Field Crest Care Center | 10 mi | ★★★★★ | 11 | 0 |
| Prairie Manor Care Center | 14.8 mi | ★★★★★ | 0 | 0 |
| Edenbrook Pine Haven | 16.1 mi | ★★★★★ | 14 | 0 |
| Edenbrook Of Rochester | 18.7 mi | ★★★★★ | 16 | 0 |
| Madonna Towers Of Rochester | 18.8 mi | ★★★★★ | 4 | 0 |
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