Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fair View Health Care Center during CMS and state inspections, most recent first.
Admission Agreement Included Improper Liability Waiver Language: The facility used an admissions agreement and Resident Handbook stating it would not be responsible for loss or damage to a resident's valuables, personal property, or money, and that no deductions or credits would be taken for such loss. Two residents had signed handbooks containing this language. The DON, corporate DON, and Administrator stated they were not aware the wording did not meet regulatory requirements.
The facility failed to designate a DFNS with the required qualifications when it did not employ a qualified RD or other clinically qualified nutrition professional full-time. The DM said he/she had no food service management degree or certification and had not previously worked as a DM, while the consultant RD worked only part-time. The administrator said he/she did not know the regulatory qualifications for the DFNS and was unaware that the DM did not meet them.
Walk-in freezer door would not fully seal shut, and observations showed thick frost on stored food, freezer walls, and the evaporator coil cabinet, along with heavy ice buildup on the floor and around the door. The DM said the issue had been present for about 8 months and had been reported multiple times to the prior maintenance director without being addressed, while the administrator said he/she was unaware of the full extent of the problem until recently.
Failure to submit complete and accurate PBJ staffing data to CMS. The facility’s PBJ report did not include staffing data for two quarters, and the DON and Administrator said corporate handled the submission and they were unaware of the reporting issue. The Regional HR Director said HR collected hours worked, sent the information quarterly, and he/she created the file for CMS submission, but had only recently taken over the role and was not aware of the prior process.
TB screening and water management documentation were incomplete. Several employees did not have TB testing completed or documented per policy, including delayed or missing 2-step PPD records, and four sampled residents lacked required TB test documentation. Staff and leadership gave differing accounts of who was responsible for ensuring testing was done. The facility also lacked a complete Legionella water management program, including a facility-specific risk assessment and documentation of routine flushing, cleaning, maintenance, and monitoring of water sources.
Care plans were not reviewed and revised for four residents after MDS assessments and current orders. One resident with cerebral palsy and quadriplegia had bilateral hand contractures and an order for resting hand splints, another resident with unilateral upper extremity impairment had an order for a left upper body brace, a third resident needed communication assistance for outside medical appointments, and a fourth resident with cerebral palsy and edema had an order for daily ace wraps. Observations showed contractures, lack of ordered supports, and swollen lower legs without ace wraps, while the care plans did not reflect these needs.
Failure to Maintain Required RN Coverage: The facility failed to provide an RN in the building for at least 8 consecutive hours a day, 7 days a week. RN schedules showed multiple weekends with no RN coverage, despite the facility policy requiring RN services daily. The DON said he/she believed an RN was rotating every other weekend and was unaware some weekends had no RN scheduled, while the Administrator acknowledged RN coverage concerns and said the DON and corporate DON covered shifts when needed but did not clock in to track RN hours.
Nurse aides were not shown to have completed CNA training within the required 120 days of hire. Four nurse aides had hire dates documented, but their CNA reports did not contain proof of completed training. Interviews showed one aide had started classes late because of instructor issues and another had completed classes but had not scheduled testing. The DON, corporate DON, and Administrator acknowledged delays tied to shared classes, staffing reliability, and trainer problems.
Expired and discontinued medications were found stored in medication carts, including eye drops, an inhaler, laxatives, seizure medications, and other oral meds past their expiration or use-by dates. Staff interviews showed the CMT, RN, and DON each described responsibility for cart checks and disposal, but there was no documented system for medication storage audits, and the Administrator expected weekly inspections and immediate removal of expired meds.
Hot food was served below the required temperature on room trays for residents who ate in their rooms. A resident tray from the 100 hall showed hot items at 103 F and 106 F, while the facility policy required hot foods to be above 135 F at service. Residents and staff reported that room trays were often cold or barely warm, and staff said those residents were typically served last.
Staff failed to maintain resident dignity by standing over residents while assisting with meals. Four residents with severely impaired cognition and dependence on staff for eating or meal assistance were observed being fed by NAs/CNAs who remained standing over them. The DON and Administrator stated staff were expected to sit at eye level during meal assistance, and the facility policy required staff to treat residents with dignity and respect.
Failure to Post Required Nurse Staffing Information: Facility staff did not post the required daily nurse staffing sheet in a place readily accessible to residents and visitors. Observations over multiple days showed the posting was absent, and the DON, corporate DON, and administrator each stated the staffing information should be posted daily, including census and total hours worked by RN, LPN/LVN, and CNA staff, but were unaware it was not being posted.
Facility staff did not ensure an RN was on duty for eight consecutive hours daily, separate from the DON, when the census was above 60. Staffing records and interviews confirmed that the DON regularly worked as the charge nurse during this period due to a shortage of RNs, despite awareness of the policy requiring separate RN coverage.
Staff did not complete or document required weekly skin assessments and physician-ordered wound treatments for three residents with significant risk factors for skin breakdown. Medical record and TAR reviews showed multiple missed assessments and undocumented treatments, despite facility policy and physician orders. Interviews with LPNs, the DON, and the Administrator confirmed these expectations and acknowledged the deficiencies in both completion and documentation.
Facility staff did not update the required Facility-Wide Assessment, resulting in missing and inaccurate information about resident census, acuity, special treatments, ADL needs, mobility, and staffing plans. Interviews with the DON and interim administrator revealed uncertainty about responsibilities and update frequency, leading to incomplete resource planning.
A resident admitted with severe cognitive impairment, acute respiratory failure, tracheostomy, Angelman syndrome, and a urinary catheter did not have a baseline care plan addressing their tracheostomy, gastrostomy tube, or urinary catheter within 48 hours of admission. Staff interviews revealed confusion about responsibility for care plan completion, and the DON acknowledged the plan was incomplete due to staffing issues.
Staff did not obtain physician orders for a resident's urinary catheter, tracheostomy, and gastrostomy tube, nor for the care and maintenance of these devices. Nursing staff and the DON were unaware of the missing orders and relied on prior experience to provide care, with responsibility for order entry and oversight not being properly executed.
The facility staff failed to follow infection control protocols during medication administration, perineal care, and glucometer disinfection. A CMT did not perform hand hygiene between residents, and CNAs did not wash hands during perineal care. An LPN used incorrect wipes for glucometer disinfection. The facility also lacked proper precautions for a resident with C-diff, and did not complete TB testing for several employees.
The facility failed to conduct required background checks, including EDL, CBC, and FCSR, for nine out of ten sampled employees before hiring. Interviews revealed confusion and lack of responsibility among staff regarding the completion of these checks, with the HR staff lacking access to complete FCSR checks and the Administrator unaware of the full requirements.
Facility staff failed to complete neurological assessments for two residents after falls, did not ensure pressure-relieving devices were used as ordered for two residents, and provided incorrect wound care for another resident. Interviews with staff, including an LPN, DON, and administrator, confirmed expectations were not met, leading to deficiencies in care.
Facility staff failed to provide scheduled bathing assistance to five residents, leading to inadequate hygiene maintenance. Despite the facility's policy, documentation showed missed showers for residents requiring assistance, with no records of refusal. Interviews confirmed that incomplete shower sheets likely indicated a lack of assistance.
The facility failed to provide a consistent activity program for residents, particularly on weekends, due to the absence of an activity director. This affected several residents who expressed a desire for activities. Staff confirmed that activities occurred randomly and infrequently, and an activities calendar was not posted as required by facility policy.
The facility failed to maintain a medication error rate below 5%, with a 20.69% error rate observed. Errors involved insulin administration without proper labeling of open and beyond use dates, and incorrect dosages. An LPN administered insulin from vials and pens missing these dates, and another resident received an incorrect insulin dose. The DON and administrator expected staff to check these dates and dosages, considering such errors as medication errors.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers or therapeutic leave. Three residents were affected, with their medical records lacking documentation of such notifications. Interviews revealed that the Social Services Director was unaware of the requirement to notify upon each discharge, and an LPN was unfamiliar with the policy. The administrator believed the discharging nurse was responsible for this task but was unaware it was not being done.
The facility failed to complete required PASRR evaluations for two residents with mental health diagnoses, including schizophrenia and PTSD, residing in Medicare/Medicaid certified units. The Director of Nursing was unsure of the responsibility for these evaluations, and the administrator could not locate the completed screenings, despite acknowledging responsibility.
Facility staff failed to ensure call lights were within reach for three residents, all of whom were severely cognitively impaired and required assistance. Observations showed call lights were often on the floor or hung on walls, making them inaccessible. Interviews with staff, including a CNA, LPN, DON, and the administrator, confirmed the expectation for call lights to be within reach, yet they could not explain the oversight.
Facility staff failed to provide residents with access to their trust fund accounts on weekends, as the policy allowed access only during business hours, Monday through Friday. The Corporate Business Office Manager was unsure of regulations regarding access outside these hours, while the Administrator acknowledged awareness of the regulation but noted that the issue had never arisen.
The facility did not complete a detailed assessment to determine staffing and resource needs for resident care during routine and emergency situations. The assessment lacked information on licensed nurses, direct care staff per resident, and assistance with activities of daily living. The facility had 53 residents with various care needs, including oxygen therapy, tracheostomy care, and behavioral health care. The Administrator was unaware of the outdated assessment and noted that a new one would be implemented by the new corporation.
Admission Agreement Included Improper Liability Waiver Language
Penalty
Summary
The facility failed to ensure its admission policy did not require residents and/or responsible parties to waive facility liability for loss or damage to personal belongings. Review of the Skilled Nursing Facility Resident Agreement showed the facility stated it would under no circumstances be held responsible for any loss or damage to valuables, personal property, or money brought to the facility, and that no deductions or credits would be taken from amounts due to the facility as a result of any loss suffered or damage done to residents' personal property. This language was identified in the agreement used by the facility. Record review showed this same language was present in the Resident Handbook signed by two residents, including one resident admitted to the facility and another resident admitted later. During interviews, the DON stated he/she was new and had not completed an admission contract with any residents and was not familiar with the policy. The corporate DON stated the admissions agreement was created at the corporate level and used at other facilities, and he/she believed it was appropriate but was not aware it did not meet regulatory requirements. The Administrator stated the admissions agreement was a standard contract used by the facility and said he/she had just been made aware of the wording about loss and/or damage to resident property and believed that statement was not agreeable to regulation.
Unqualified DFNS Without Full-Time Clinically Qualified Nutrition Staff
Penalty
Summary
The facility failed to designate a person to serve as the Director of Food and Nutrition Services (DFNS) with the required qualifications when it did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The deficiency affected the facility census of 53.1 residents. Review of the Dietary Manager job description, dated 2023, showed the DFNS was required to meet State requirements for food service managers or dietary managers and also meet one of several qualification pathways, including certification, a related degree, or prior DFNS experience with completed food safety and management coursework. Review of the Dietary Manager personnel record showed a hire date for the DFNS position of 03/12/26, but the record did not contain documentation of prior DFNS experience in a nursing facility or the certification or education required for the position. During interview, the DM stated he/she became the DM in mid-March 2026, did not have a degree or certification related to food service management, and had not previously worked as a DM. The DM also stated the facility's consultant RD worked only part-time and that no other clinically qualified nutritional staff were employed full-time. The administrator stated he/she did not know the DFNS qualifications required by regulation, did not know the DM did not meet them, and was not aware of any other clinically qualified nutritional staff employed full-time at the facility.
Walk-In Freezer Not Sealing Properly With Heavy Frost and Ice Accumulation
Penalty
Summary
The facility failed to maintain the walk-in freezer in a manner to prevent potential food contamination. Observation on 04/19/26 at 10:24 A.M. showed the walk-in freezer door was unable to fully seal shut, with thick frost accumulation on the freezer walls, the evaporator coil cabinet, and most of the food stored inside the freezer. A thick layer of ice was also observed on the front and back of the evaporator coil cabinet and on the floor inside the freezer. A later observation on 04/20/16 at 10:18 A.M. again showed the walk-in freezer door unable to fully seal shut, with thick frost on most stored food items, the freezer walls, and the evaporator coil cabinet. Thick ice was also observed on the freezer floor, on the side of the freezer door, and on the front and back of the evaporator coil cabinet. The maintenance director said he/she had only recently learned of the door issue, while the dietary manager said the door had not fully sealed since he/she started about eight months earlier and that the frost and ice had gradually worsened over that time. The dietary manager also said the issue had been reported multiple times to the previous maintenance director, but it was never addressed. The administrator said he/she did not know about the freezer condition until the prior week and did not know how long the door had been unable to fully seal or how much frost and ice had accumulated.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) for the first and second quarter of 2025. Review of the facility’s RN policy, revised 04/30/24, showed the facility is responsible for submitting timely and accurate staffing data through the CMS PBJ system. Review of the CMS PBJ Staffing Data Report, dated April 17, 2026, did not contain a report for the first and second quarter of 2025. During interviews, the DON stated the corporate office was responsible for reporting staffing information to PBJ and was not aware the PBJ was not reported correctly for 2025. The Administrator also stated he/she was not aware there were issues with PBJ reporting and said the corporate office handles the final submission. The Regional Human Resource Director stated the facility HR Director collects hours worked information, sends it quarterly, and that he/she compares it to the system and creates the file to submit to CMS; he/she had just taken over the position in November 2025 and was not aware of the previous process.
TB Screening and Water Management Documentation Failures
Penalty
Summary
Facility staff failed to follow infection prevention and control procedures related to tuberculosis screening for employees and residents. Review of the facility’s TB testing policy showed new employees were to receive a 2-step PPD upon hire and annual TB testing, and residents were to receive a 2-step PPD upon admission or readmission and annual TB testing as ordered. In review of 10 employee files, five employees did not have TB testing completed and documented in accordance with the policy, including a dietary aide, an LPN, a CMT, an RN, and another employee whose records showed incomplete or improperly timed testing documentation. The employee records showed several examples of incomplete or delayed testing. One dietary aide and one LPN had first-step TB tests documented after their hire dates, another employee had first- and second-step TB tests documented months after hire, one CMT had only a first-step TB test documented with no second-step test on file, and one RN had TB test documentation without recorded read dates. During interviews, the DON, Administrator, and BOM each described different responsibilities for ensuring TB testing was completed, and the BOM stated staff were scheduled for TB tests before starting work but that missed tests occurred when employees did not show or nurses did not administer them. Resident TB screening was also incomplete. Review of five sampled resident records showed four residents did not have documentation of the required first-step and/or second-step TB tests in their medical records. The Corporate DON stated residents were expected to have the first-step TB test upon admission and the second-step within 14 days, and believed the issue was that information was not flowing through the EMR to trigger the tests. The Administrator stated the DON was ultimately responsible for ensuring resident TB testing was completed and noted there had been significant turnover in the DON position. The facility also failed to develop and implement complete water management documentation to address Legionella prevention. The facility’s policy required maintaining potable water systems in a clean condition, controlling temperatures, minimizing stagnation, identifying dead legs and low-use conditions, performing routine flushing and monitoring, and documenting all monitoring and corrective actions. However, the Water Management Program did not contain a facility-specific risk assessment, identification of dead legs or low-use conditions, or documentation of routine flushing, cleaning, maintenance, and monitoring. During the Life Safety Code tour, the facility was observed to have a cooling tower, multiple ice machines, and multiple water sources, and staff stated they could not locate the risk assessment or documentation of routine water system monitoring and maintenance.
Care Plans Not Updated for Ordered Interventions and Resident Needs
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for four sampled residents after comprehensive or quarterly MDS assessments. The facility’s policy stated that care plans would be based on the resident’s strengths, needs, and cultural preferences, and would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The report identified that the care plans for Resident #4, Resident #5, Resident #10, and Resident #22 did not reflect current assessed needs or ordered interventions. Resident #4 had severe cognitive impairment, bilateral upper and lower extremity impairment, and was dependent on staff for eating, toileting, showering/bathing, and personal hygiene. The resident also had diagnoses of cerebral palsy and quadriplegia, and the physician order sheet showed an order to wear bilateral resting hand splints as tolerated during the day. The care plan dated 04/2026 did not address the resident’s contractures or interventions. Observations on multiple dates showed the resident in a specialized medical wheelchair or in bed with both hands contracted and no interventions in place. Resident #5 was cognitively intact with upper extremity impairment to one side and required substantial to maximal assistance with toileting hygiene and showering/bathing, and moderate assistance with upper body dressing and personal hygiene. The physician order sheet showed an order for a left upper body brace, but the care plan dated 02/27/26 did not address the resident’s contracture. Resident #10’s annual MDS indicated a need or desire for assistance communicating with doctors and health care staff, and nursing progress notes showed outside medical appointments, but the care plan dated 01/28/26 did not reflect the need for communication assistance during appointments. Resident #22 had severely impaired cognition, bilateral upper extremity impairment, dependence on staff for multiple ADLs, and a diagnosis of cerebral palsy; the care plan dated 2/16/26 did not direct staff to use ace wraps for edema or address new edema interventions, even though the physician order sheet showed an order for bilateral lower legs to be ace wrapped daily for edema and observations showed swollen bilateral lower legs without ace wraps in place.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility 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 would utilize the services of an RN for at least eight consecutive hours per day, seven days a week, but review of the RN staff schedules showed multiple days in January, February, March, and April 2026 when no RN was in the building for the required coverage period. The RN schedule showed no RN coverage on several Saturdays and Sundays across those months, including 01/03/26, 01/04/26, 01/17/26, 01/18/26, 01/31/26, 02/01/26, 02/14/26, 02/15/26, 02/28/26, 02/29/26, 03/14/26, 03/15/26, 03/28/26, 03/29/26, 04/11/26, and 04/12/26. During interview, the DON stated the facility was required to have an RN in the building seven days a week for eight consecutive hours a day and said he/she thought an RN was rotating every other weekend, but was not aware some weekends had no RN scheduled. The Administrator stated the facility should have an RN on every day shift for 8 consecutive hours, acknowledged concerns with RN coverage, and said the facility had been recruiting RNs; the Administrator also stated the DON and corporate DON covered shifts when needed but did not clock in to track RN hours in the building.
Nurse Aides Not Trained Within Required Timeframe
Penalty
Summary
Facility staff failed to ensure that four nurse aides completed the nurse aide training program within four months of employment. Review of the facility’s policies showed staff did not provide a policy directing staff on nurse aide qualifications. Record review showed NA A had a hire date of 09/15/25, NA B had a hire date of 08/23/25, NA C had a hire date of 03/06/23, and NA D had a hire date of 11/21/25, and none of their CNA reports contained documentation that they completed a nurse aide training program. During interviews, NA B stated he/she started in August 2025, had never worked in another department, and had started classes a few months ago after delays related to not having an instructor; he/she said classes were completed but testing had not been scheduled. NA D stated he/she had worked at the facility for four to five months and previously worked at another one of the homes for seven months as an NA; he/she said classes were completed but a test date had not been set. The DON stated he/she knew the requirement was for the NA to complete the CNA training course within 120 days of hire, but was not sure why the training had not been completed and said he/she had only been DON for 29 days. The corporate DON stated the facility was sharing CNA classes with sister facilities and that some staff were not reliable with attending classes, while the Administrator stated there had been issues with completing classes timely after a teacher walked out and the facility had to work with a sister facility to get a new trainer.
Expired Medications Found in Medication Carts
Penalty
Summary
Facility staff failed to ensure medications were stored in a safe and effective manner when expired and discontinued medications were left in medication carts. Review of the facility policy dated 05/18/24 showed medications housed in the facility premises were to follow the manufacturer's recommendations related to unused medications. On 04/19/26, observation of the 200 hall medication cart found multiple medications past their expiration or use-by dates, including Prednisolone Acetate ophthalmic suspension, Systane Balance lubricant eye drops, an Albuterol inhaler, and Bisacodyl tablets. A later observation of the 200 hall overflow medication cart found additional expired or past-use medications, including Levetiracetam oral solution, Lactulose oral solution, Valproic acid, Stomach Relief Pink Bismuth, Baclofen, Senexon-S, and Ondansetron. During interviews, the CMT said he/she was responsible for checking the cart and discarding expired or discontinued medications, but was unsure whether there was a documented system for medication storage completion. The RN said he/she was primarily responsible for the medication cart and reconciled medications, while the DON said CMTs were to dispose of medications and that there was no system in place to ensure proper medication storage audits. The Administrator said expired or discontinued medications should be removed immediately and expected weekly inspections of medication carts.
Hot Food Served at Unsafe Temperatures on Room Trays
Penalty
Summary
Prepared hot food items were not maintained at a safe and appetizing temperature when served to residents who ate in their rooms. The facility policy titled, Dietary Food Preparation, dated 07/05/23, stated hot food items are expected to be greater than 135 F at the time of service. During observation of lunch tray service from the 100 hall food cart, a resident tray showed rosemary herbed baked chicken and cauliflower au gratin at 103 F and mushroom rice at 106 F. The menu for that meal included rosemary herbed baked chicken, mushroom rice, and cauliflower au gratin for residents on a regular diet. Residents and staff reported that hot food delivered to room trays was often cold or barely warm. Two residents stated their food was mostly cold or barely warm when delivered to their rooms. A CMT said residents on the 100 hall who eat in their rooms complain nearly every day about cold hot food and are served last. A CNA also said residents who choose to eat in their rooms frequently complain about receiving cold meal trays. A DA said it can take a while to dish up plates for room trays and that the residents on the 100 hall are the last residents served. The DM stated hot food should be served at 120 F or higher regardless of where residents eat, and the administrator stated the DM was responsible for ensuring hot food was served at 120 F or higher.
Staff stood over residents during meal assistance
Penalty
Summary
Facility staff failed to maintain resident dignity when they stood over residents while assisting them with meals. Observation, interview, and record review showed Nurse Aides and a CNA stood over four residents during feeding assistance. The facility’s Promoting/Maintaining Resident Dignity policy stated staff are to speak to and treat residents with dignity and respect and pay attention to the resident as an individual when interacting with them. Resident #4’s quarterly MDS showed severely impaired cognition, impairment of both upper extremities, and dependence on staff for eating, but the care plan did not direct staff on how to assist with meals. Resident #22’s quarterly MDS showed severely impaired cognition, impairment of both upper extremities, and dependence on staff for eating; the care plan stated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits. Resident #23’s quarterly MDS showed severely impaired cognition, impairment of both upper extremities, and dependence on staff for eating, and the care plan stated the resident had dysphagia and needed assistance and encouragement with meals and fluids. Resident #34’s quarterly MDS showed severely impaired cognition and substantial maximal assistance with meals, and the care plan stated the resident did not feed himself/herself and required staff assistance and encouragement. The DON and Administrator stated staff were expected to sit at eye level while assisting residents with meals and were not aware staff were standing during meal assistance.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
Facility staff failed to complete or post the required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 53.1. The facility policy titled, Nurse Staffing Posting Information Policy, reviewed 06/26/24, required the nurse staffing sheet to be posted daily at the beginning of each shift and to include the facility name, current date, current resident census, and the total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift in a clear, readable format in a prominent place accessible to residents and visitors. Observations on 04/19/26 at 10:30 A.M., 04/20/26 at 11:00 A.M., 04/21/26 at 5:10 P.M., and 04/22/26 at 3:04 P.M. showed the nurse staff posting sheet was not posted in an area readily accessible to residents and visitors. During interviews on 04/22/26, the DON stated the daily staff schedule should be posted at the nurse station and that the staffing coordinator was responsible for posting it daily, but said he/she was not aware it was not being posted with the correct information. The corporate DON stated the daily staffing should be posted at the nurse station and include total hours worked per day/per shift for each direct care staff and the census for the day, and said he/she was not aware it was not being posted. The administrator also stated the daily staffing numbers should be posted daily where residents and visitors can see it and said he/she was not aware it was not being posted.
Failure to Provide Required RN Coverage When Census Exceeds 60 Residents
Penalty
Summary
Facility staff failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, separate from the Director of Nursing (DON), when the facility census exceeded 60 residents. Review of staffing sheets and census records over multiple dates showed that the DON regularly worked as the charge nurse during times when the census was above 60, contrary to the facility's own policy and regulatory requirements. The policy specifies that the DON may only serve as a charge nurse when the average daily occupancy is 60 or fewer residents. Interviews with the Administrator, staffing coordinator, and DON confirmed that the DON had been working as the RN charge nurse for several weeks due to a shortage of available RNs. The facility had only one other RN on staff, and both the DON and this RN alternated to cover required RN hours. The Administrator and DON acknowledged awareness of the requirement that the DON should not be counted as the floor RN when the census is above 60, but cited ongoing staffing challenges as the reason for noncompliance.
Failure to Complete and Document Weekly Skin Assessments and Wound Treatments
Penalty
Summary
Facility staff failed to meet professional standards by not completing and documenting weekly skin assessments and physician-ordered wound treatments for three residents out of a sample of six. The facility's policy required licensed or registered nurses to conduct full body skin assessments upon admission and weekly thereafter, as well as after any change in condition or new pressure injury. However, medical record reviews revealed multiple weeks where no documentation of these assessments was present for the affected residents. The residents involved had significant medical histories, including diagnoses such as stroke, pressure ulcers, chronic non-pressure ulcers, Parkinson's disease with dyskinesia, and immobility, all of which increased their risk for skin breakdown. Physician orders for these residents included specific wound care treatments and the use of barrier creams, which were to be documented on the Treatment Administration Record (TAR). Review of the TARs showed numerous dates where staff did not document that wound care was provided as ordered. Interviews with nursing staff, the DON, and the Administrator confirmed that weekly skin assessments and wound care documentation were expected responsibilities. Staff acknowledged that missing documentation on the TAR typically indicated that treatments were not completed. The DON admitted awareness of lapses in completing skin assessments but was not aware of the extent of missing documentation for wound care treatments.
Failure to Update Facility-Wide Assessment and Resource Planning
Penalty
Summary
Facility staff failed to update the Facility-Wide Assessment, which is required to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment tool, last dated 9/13/24, was missing critical information, including the names of persons involved in completing the assessment, dates of review with the QAA/QAPI committee, and accurate data on resident census, acuity levels, special treatments, ADL assistance needs, mobility, and the average daily staffing plan. These omissions meant the assessment did not accurately reflect the facility's current resident population or resource needs. Interviews with the DON and interim administrator revealed confusion regarding responsibilities for updating the assessment and the frequency with which updates should occur. The DON believed the administrator was responsible for updating the census and was unsure if the administrator knew how often the assessment should be updated. The interim administrator confirmed that the assessment should be updated annually and as needed, such as with changes in administration, DON, staffing requirements, resident acuity, or census, but could not explain why this had not been done.
Failure to Develop Comprehensive Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered baseline care plan within 48 hours of admission for one resident. The facility's policy requires that a baseline care plan be created within 48 hours, incorporating information from the admission assessment, hospital transfer documents, physician orders, and discussions with the resident and their representative. For the resident in question, who was admitted with severe cognitive impairment, acute respiratory failure, tracheostomy, Angelman syndrome, and a urinary catheter, the baseline care plan did not address critical needs such as the tracheostomy, gastrostomy tube, or urinary catheter. Interviews with staff revealed confusion and lack of clarity regarding responsibility for completing and verifying baseline care plans. The DON acknowledged that the baseline care plan was incomplete and attributed this to the absence of an MDS coordinator, resulting in the DON taking on the responsibility but not completing the required documentation. Other nursing staff were either unsure of how to access or update care plans or unclear about who was responsible for ensuring their completion. The administrator confirmed that nursing staff are responsible for completing baseline care plans, with the DON overseeing their completion.
Failure to Obtain Physician Orders for Critical Medical Devices and Care
Penalty
Summary
Facility staff failed to meet professional standards of quality by not obtaining physician orders for a urinary catheter, catheter care, tracheostomy, tracheostomy care, gastrostomy tube, gastrostomy tube care, or gastrostomy tube flushes for one resident. The resident, who was newly admitted, had severe cognitive impairment and diagnoses including acute respiratory failure, tracheostomy status, Angelman syndrome, and a urinary catheter. The clinical admission assessment documented the presence of a tracheostomy and urinary catheter but did not mention the gastrostomy tube, and the baseline care plan did not address these devices or their care. The physician's order sheet for the resident did not contain any orders related to these medical devices or their required care. Interviews with nursing staff and the Director of Nursing (DON) revealed that the charge nurse is responsible for entering orders for new admissions, while the DON is responsible for ensuring the orders are entered correctly. Staff were unaware that the necessary orders were missing from the system and relied on their prior nursing knowledge to provide care. The DON acknowledged a lack of knowledge among nurses regarding the process, and ongoing training was mentioned. The administrator confirmed that nursing staff are responsible for entering new admission orders, with oversight by the DON.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to infection prevention and control protocols during medication administration, perineal care, and glucometer disinfection. Certified Medication Technician (CMT) A did not perform hand hygiene between administering medications to multiple residents, despite knowing the importance of doing so. This lapse in protocol was acknowledged by the CMT, who attributed it to nerves and a lack of reeducation beyond initial training. Similarly, during perineal care, Certified Nurse Aides (CNAs) failed to wash their hands before and after glove use, increasing the risk of infection spread. The facility also failed to follow proper procedures for cleaning and disinfecting glucometers. An LPN used alcohol wipes instead of the required EPA-registered disinfectant wipes, which do not effectively kill bloodborne pathogens. This practice was not aligned with the facility's policy, and the LPN admitted to forgetting the correct procedure. The Infection Preventionist and Director of Nursing were unaware of this deviation from protocol, indicating a gap in oversight and training. Additionally, the facility did not implement appropriate transmission-based precautions for a resident with Clostridium difficile (C-diff) infection. There was no signage or personal protective equipment (PPE) available in or near the resident's room, and staff did not consistently use gowns and gloves as required. The Infection Preventionist and Director of Nursing were not fully aware of the necessary precautions, leading to inadequate infection control measures. Furthermore, the facility did not complete the two-step purified protein derivative (PPD) skin test for tuberculosis for several employees, as required by their policy, potentially exposing residents to TB.
Failure to Conduct Pre-Hire Background Checks
Penalty
Summary
The facility failed to adhere to its policy of conducting necessary background checks prior to hiring new employees. Specifically, the facility did not complete the Employee Disqualification List (EDL), Criminal Background Check (CBC), and Family Care Safety Registry (FCSR) screenings for nine out of ten sampled employees before their hire dates. These employees included a Registered Nurse, Nurse Aide, Certified Medication Technician, Dietary Aide, Laundry Aide, Housekeeping Aide, Maintenance staff, and two Certified Nurse Aides. The facility's policy, revised in May 2024, mandates that these checks be completed before hiring, but records showed that this was not done for the employees in question. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of these background checks. The Human Resources (HR) staff, who had been in the position for only two weeks, stated that they were responsible for onboarding new employees and conducting background checks, but they did not have access to complete FCSR checks yet. The Director of Nursing (DON) and the Administrator were unaware that some staff had been hired without the required screenings. The Administrator mentioned that prior to new ownership, the Business Office Manager (BOM) and they would collaborate on these checks, but with the new ownership, it became HR's responsibility. The Administrator was also unaware that all checks needed to be completed before hiring, believing that completing the EDL was sufficient.
Failure to Adhere to Professional Standards and Physician Orders
Penalty
Summary
The facility staff failed to adhere to professional standards of quality care by not completing necessary neurological assessments for two residents following falls. Resident #3, who had severe cognitive impairment and a diagnosis of dementia, experienced two falls resulting in head injuries. However, the medical records lacked documentation of neurological assessments or continuous monitoring for these incidents. Similarly, Resident #18, also with severe cognitive impairment and dependent on staff for all activities of daily living, was found on the floor, but no neurological assessment or continuous monitoring was documented. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the administrator, confirmed that neurological checks were expected but not performed or documented. The facility also failed to ensure the use of pressure-relieving devices as ordered for two residents. Resident #20, with severe cognitive impairment and upper extremity impairments, was observed multiple times without therapy carrots in place for hand contractures, despite physician orders. Similarly, Resident #22, with severe cognitive impairment and upper extremity impairments, was observed without hand rolls or pillows as ordered to alleviate pressure from contractures. Interviews with the occupational therapist, CMT, LPN, and DON revealed a lack of adherence to physician orders and a failure to ensure the prescribed treatments were administered. Additionally, the facility did not provide wound care treatment per physician orders for Resident #40, who had severe cognitive impairment and two unstageable pressure ulcers. The resident's care plan and physician orders specified a particular wound care regimen, but during an observation, an LPN used incorrect materials for the dressing change, based on a misunderstanding of the orders. The DON and administrator acknowledged the expectation for nurses to follow physician orders and the need for order clarification, but this was not done, leading to improper wound care treatment.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility staff failed to provide adequate bathing assistance to maintain proper hygiene for five residents who required assistance with their Activities of Daily Living (ADLs). The facility's Resident Showers Policy, revised in June 2024, mandates that residents should be provided showers as per request or facility schedule, with partial baths given between regular schedules. However, documentation and interviews revealed that several residents did not receive the scheduled showers or baths, and there was no documentation of refusal by the residents. Resident #15, who is cognitively intact and able to shower with assistance, did not receive scheduled showers on multiple occasions from June to August 2024. The resident reported not having received a bath or shower for about four weeks, despite being scheduled for showers twice a week. Similarly, Resident #26, who is dependent on staff for bed baths due to lower extremity impairment, did not receive any documented bed baths on scheduled days in June and July, and only one in August. The resident expressed difficulty in getting staff assistance for bed baths, resorting to using air fresheners to mask body odor. Resident #35, with severe cognitive impairment and dependent on staff for personal hygiene, also missed several scheduled showers from June to August 2024. Observations noted the resident with unkempt hair, indicating a lack of hygiene care. Resident #37, who requires moderate assistance, and Resident #38, with severe cognitive impairment and dependent on staff, both experienced similar issues with missed showers and lack of documentation. Interviews with nursing assistants and the Director of Nursing confirmed that if shower sheets were not completed, it likely indicated that the residents were not assisted with their scheduled showers.
Lack of Consistent Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs, interests, and well-being of residents, particularly on weekends. This deficiency affected four residents out of a sample of 14, as the facility did not have scheduled activities on several weekends in July and August 2024. Additionally, the facility did not post an activities calendar for residents to view, as observed on multiple occasions from August 26 to August 29, 2024. Interviews with residents revealed that they had not participated in activities for several months due to the absence of an activity director, and they expressed a desire for activities such as Bingo and Yahtzee. Staff interviews confirmed the lack of a consistent activity program. A CNA and an LPN mentioned that activities occurred randomly and infrequently due to the absence of an activity director. The Director of Nursing and the administrator acknowledged that the facility had not had consistent activities since the departure of the activity director, and they admitted that an activities calendar had not been posted recently. The facility's policy required an ongoing program of activities to promote residents' emotional health and self-esteem, but this was not being fulfilled due to staffing issues.
Medication Error Rate Exceeds 5% Due to Insulin Administration Issues
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 20.69% error rate during the survey. Out of 29 medication administration opportunities observed, six errors were identified, affecting four residents. The errors primarily involved the administration of insulin without proper labeling of open and beyond use dates, as well as incorrect dosages being administered. Resident #23 was administered Lispro insulin from a vial that lacked a beyond use date. Similarly, Resident #26 received Aspart insulin from a pen with an illegible open date and no beyond use date. Resident #31 was given Glargine and Fiasp insulin from pens and vials that were either missing open dates or beyond use dates. In each case, the LPN involved was unaware of the importance of these dates and the potential for the insulin to be expired. Resident #58 was administered an incorrect dose of Aspart insulin, receiving only four units instead of the prescribed six units. The LPN acknowledged the error upon review of the physician's order sheet. Interviews with the DON and the administrator revealed that it was expected for staff to check open and expiration dates before administering insulin, and that administering expired insulin or incorrect dosages constituted medication errors.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents out of a sample of three, with the facility's census being 53. The facility's policies did not include a procedure for bed hold notification, and the medical records of the affected residents lacked documentation of such notifications. Specifically, Resident #22 was discharged and readmitted without any written notification of the bed hold policy. Similarly, Resident #36 experienced multiple discharges and readmissions without receiving the required notification, and Resident #47's records also lacked documentation of bed hold policy notification upon discharge and readmission. Interviews with facility staff revealed a lack of awareness and understanding of the bed hold notification process. The Social Services Director (SSD) admitted to only providing bed hold information at the time of admission and was unaware of the requirement to do so upon each discharge for hospital or therapeutic leave. An LPN expressed unfamiliarity with the bed hold policy, assuming it was the responsibility of the SSD. The facility administrator believed that the discharging nurse was responsible for completing the bed hold notification and stated that staff had been in-serviced on this process, but was unaware that it was not being consistently implemented.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Level I Pre-Admission Screening and Resident Review (PASRR) evaluations were completed for two residents, both of whom were residing in Medicare and/or Medicaid certified units. The PASRR is a federally mandated screening process designed to evaluate individuals for serious mental illness or intellectual disabilities to ensure appropriate placement and care. The facility's policies did not include a policy for PASRR, and the Director of Nursing was unsure who was responsible for completing these evaluations. The administrator acknowledged responsibility for completing PASRR evaluations but could not locate the completed screenings for the two residents in question. Resident #8 was assessed with moderate cognitive impairment and had diagnoses of anxiety disorder, depression, and schizophrenia. The resident was receiving antipsychotic, antianxiety, and antidepressant medications, yet their medical record lacked a Level I Pre-Admission Screening or PASRR Level II screen. Similarly, Resident #26, who was cognitively intact and diagnosed with anxiety disorder, depression, and PTSD, also did not have the required PASRR evaluations in their medical record. Both residents were receiving relevant medications, indicating the necessity for such screenings to ensure their needs were being met appropriately.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility staff failed to ensure that call lights were within reach for three residents, leading to a deficiency in the accessibility of the call system. Resident #10, who was severely cognitively impaired and dependent on staff for activities of daily living and transfers, was observed multiple times with the call light either on the floor or hung on the wall behind the bed, making it inaccessible. Similarly, Resident #27, who was legally blind and required substantial assistance, was found in a wheelchair with the call light placed on the bed or hung on the wall, out of reach. Resident #40, also severely cognitively impaired and dependent on staff, was repeatedly observed with the call light on the floor beside the bed, not within reach. Interviews with facility staff, including a CNA, an LPN, the Director of Nursing, and the administrator, confirmed that call lights should always be within reach of residents to prevent falls and ensure they can request help. Despite this understanding, the staff was unable to explain why the call lights were not accessible to the residents in question. The facility's policy mandates that call lights be accessible to residents at all times, yet observations indicated a failure to adhere to this policy, resulting in a deficiency in resident care.
Inadequate Access to Resident Trust Funds on Weekends
Penalty
Summary
Facility staff failed to ensure residents had appropriate access to their trust fund accounts on weekends. The facility's Resident Trust Policy, dated February 2, 2024, and the Admission Packet both indicated that residents could access their personal possessions and funds only during regular business hours, Monday through Friday. During an interview, the Corporate Business Office Manager confirmed that the corporation policy restricted access to business hours and was unsure of the regulations regarding access outside these hours. The Administrator acknowledged awareness of the regulation but mentioned that the issue of weekend access had never arisen, and if necessary, a nurse could cover money for a resident, with reimbursement from the facility's petty cash later.
Incomplete Facility Assessment for Staffing and Resident Care Needs
Penalty
Summary
The facility failed to develop a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated 01/20/24, was incomplete, lacking details on the number of licensed nurses and direct care staff per resident, as well as assistance with activities of daily living. The facility census was 53, with specific care needs including oxygen therapy, tracheostomy care, BIPAP/CPAP, behavioral health care, injections, dialysis, ostomy care, and hospice care. During an interview, the Administrator acknowledged her responsibility to update the facility assessment but was unaware that it had not been updated. She mentioned that a new assessment would be implemented by the corporation that recently took over.
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What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sedalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sylvia G Thompson Residence Center, Inc | 1.3 mi | ★★★★★ | 11 | 0 |
| Rest Haven Health Care Center | 1.4 mi | ★★★★★ | 4 | 1 |
| E W Thompson Health & Rehabilitation Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Four Seasons Living Center | 5.3 mi | ★★★★★ | 33 | 1 |
| Good Samaritan Care Center | 16.6 mi | ★★★★★ | 0 | 0 |
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