Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Fleshers Fairview Health Care during CMS and state inspections, most recent first.
The facility failed to promptly notify physicians of significant changes in condition for four residents, including the development of new pressure ulcers, a diabetic foot ulcer, and significant weight loss. In each case, staff either delayed or omitted notification to the physician or nurse practitioner, resulting in a lack of timely medical intervention and documentation. Interviews with clinical staff and review of records confirmed that the required notifications were not made as expected.
Due to ongoing staffing shortages, the facility failed to provide adequate ADL care, including missed showers for multiple residents, and did not consistently assess or treat pressure ulcers. Staff, including the Wound Nurse, were frequently reassigned to cover other duties, resulting in delayed wound assessments, incomplete documentation, and lapses in necessary medical care for residents with pressure ulcers and diabetes.
A resident with severe cognitive impairment and multiple comorbidities did not receive timely skin assessments or prompt identification of a new heel wound. Communication failures among staff led to a delay in notifying providers and in initiating antibiotic treatment after a wound culture showed infection, resulting in delayed care for the resident's wound.
Two residents at risk for pressure ulcers did not receive timely or adequate skin assessments, wound measurements, or appropriate treatment orders. In both cases, pressure ulcers were not promptly assessed or reported, and treatment orders were either delayed or not renewed, resulting in wounds going untreated and worsening in severity. Nursing staff failed to follow wound care protocols, and there was poor communication and documentation regarding wound care.
Two residents with cognitive and mobility impairments were not adequately supervised, resulting in one resident sustaining a left ankle fracture after being left unsupervised in the bathroom, and another resident with dementia eloping from the facility on two occasions. Staff interviews and documentation revealed inconsistent communication and lack of effective interventions to prevent falls and elopement.
Over several months, residents repeatedly voiced concerns during Resident Council meetings about staff cell phone use during work, slow call bell response times on second shift, and early morning ice distribution that disrupted sleep. Despite these ongoing complaints, facility responses remained largely unchanged, with assurances of monitoring and staff discussions but no effective resolution. Residents reported feeling their concerns were not taken seriously, and interviews with staff confirmed the persistence of these unresolved issues.
The facility did not provide two residents and their representatives with written information about advance directives or the right to accept or refuse medical or surgical treatment at admission. Interviews confirmed that only the MOST form was discussed, and neither written materials nor acknowledgment checklists were included in the admission process. Both residents and their representatives were unaware of advance directives, and staff admitted to not providing the required information.
Two dependent residents did not receive scheduled showers on multiple occasions because the designated shower team NAs were frequently reassigned to floor duties due to staffing shortages, and no process existed to ensure showers were provided by other staff. Facility leadership and staff interviews confirmed that missed showers were not rescheduled, and the issue persisted due to inadequate staffing and lack of a backup plan.
Confidential medical information, including a resident's narcotic sheet and two medication cards with residents' names and medication details, was left unattended and visible on a medication cart. No nurse was present, and the information was accessible to staff and a resident passing by. The nurse later acknowledged the privacy breach, and the DON confirmed it was a HIPAA violation.
A resident with dementia was physically abused by a staff member during care, but the incident was not immediately reported or acted upon by the witnessing nurse aide or nursing staff. The accused staff member continued working for the remainder of the shift, and the facility failed to promptly protect the resident or investigate whether other residents were affected, in violation of abuse prevention and reporting policies.
Two residents were incorrectly coded on their MDS assessments regarding PASRR Level II status, despite having Level II determinations in their records, due to staff input errors. Additionally, a resident was inaccurately coded as having a stage 1 pressure ulcer on the MDS, even though the wound developed after the assessment date.
A resident with severe cognitive impairment and multiple comorbidities developed an unstageable pressure ulcer after admission, but the care plan was not updated to address this new condition. Although the wound was identified and treatment orders were obtained, the MDS nurse did not revise the care plan as required, despite being informed of the new development.
A resident with dementia and malnutrition experienced significant unaddressed weight loss after staff failed to promptly reweigh her and report the results, despite a dietitian's recommendation. The reweight was delayed, not documented, and not communicated to nursing management or the physician, and the resident continued to receive inadequate assistance and encouragement during meals.
Surveyors found that several residents receiving oxygen therapy did not have their oxygen concentrator filters cleaned as required, lacked proper oxygen in use signage on their room entrances, and had oxygen tanks that were not properly secured or transported. Staff interviews revealed confusion about cleaning schedules, signage responsibilities, and safe handling procedures for oxygen equipment.
A staff member was employed as a nurse aide and assigned direct care tasks without having completed a state-approved NA training program, certification exam, or competency evaluation, and was not actively enrolled in a training program. The facility's practice allowed staff to work as NAs before enrollment in a program, contrary to regulatory requirements.
Surveyors found that medication carts contained loose, unlabeled pills and open, undated boxes of inhalation solutions, including budesonide, albuterol sulfate, and DuoNeb, which were not stored according to manufacturer guidelines. Nurses responsible for the carts were unaware of proper storage and labeling requirements, and the DON indicated that both individual nurses and the weekend supervisor share responsibility for maintaining medication cart organization.
A resident with multiple wounds, including a left heel wound suspected of infection, experienced a delay in antibiotic treatment after a positive wound culture result was not promptly communicated to the Wound Provider or NP. The Wound Nurse incorrectly reported the culture as negative without reviewing the results, and the actual findings were not shared with the providers until several days later, resulting in a missed day of necessary antibiotic therapy.
A Wound Nurse failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies during wound care for two residents with open wounds, including not donning a gown, not changing gloves, and not performing hand hygiene at required intervals. The nurse and facility leadership misunderstood CDC guidelines, resulting in the absence of EBP for residents with open, draining wounds.
Surveyors found that two dryers in the laundry room had significant lint and dust buildup, with lint traps containing thick sheets of lint. Despite staff claims of daily cleaning, the accumulation remained unexplained, and the Environmental Services Supervisor acknowledged that the cleaning frequency was not adequate.
Two residents experienced a lack of dignity during meal service: one was left waiting for her meal while others at her table were served, and another was fed by a nursing assistant who did not sit at eye level as required. Both incidents involved residents with cognitive impairment and special dietary needs.
A resident with severe cognitive impairment and a history of combative behavior was physically abused by a staff member during incontinence care. The staff member became angry at the resident's resistance, grabbed her wrists, and slapped her hand with an open hand, as witnessed by another aide. The incident led to the resident displaying fearful behavior towards staff and was later substantiated as abuse by the facility.
The facility did not post Nurse Staffing Information in a location that was easily accessible and failed to accurately complete the posted sheets, including incorrect census data and discrepancies between posted and actual staffing, as well as omitting Temporary Nurse Aides from the records.
Surveyors found that both laundry rooms had significant dust accumulation and improper storage of residents' clean clothing, including proximity to unclean housekeeping carts and storage of dusty items above clean laundry. Additionally, a pill crusher on a medication cart was observed to be visibly soiled with dried liquid and debris, with staff interviews confirming that cleaning responsibilities were not consistently followed.
A resident with functional quadriplegia and dementia fell from her bed during a bed bath, resulting in a fractured femur. The resident was resistant to care, and the nursing aide left her unattended on her side near the bed's edge. The resident lowered her leg, causing her to fall off the bed, hit a chair, and then the floor. The facility failed to provide adequate supervision and a safe environment, leading to the resident's injury.
The facility failed to ensure nursing staff were competent in glucometer disinfection, as observed in five out of six staff members. Nurses used improper methods, such as alcohol wipes, due to a lack of specific training. The skills checklist did not include glucometer disinfection, and an in-service was not mandatory, leading to inconsistent knowledge among staff.
A resident's antifungal powder was found unsecured at bedside without a self-administration order, and a medication cart was left unlocked and unattended in a hallway. The resident, with moderate cognitive impairment, required assistance with daily activities. The DON and Assistant Administrator confirmed the need for secure storage of medications.
A resident with severe cognitive impairment did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) upon discharge from Medicare Part A services. The Business Office Manager issued a Notice of Medicare Non-Coverage (NOMNC) instead, due to a misunderstanding of the requirements.
A resident with COPD missed two doses of Doxycycline due to a delay in pharmacy delivery. The medication was not available in the facility's emergency backup kit, and the pharmacy was closed for a holiday. Nurses on duty did not contact the pharmacy, assuming the medication would arrive with the next delivery.
A resident with COPD did not receive an ordered antibiotic on time due to a series of oversights. The medication was not available in the emergency kit, and staff did not contact the on-call pharmacist despite a holiday affecting pharmacy deliveries. The delay exceeded 24 hours, which was deemed too long by the Medical Director.
A deficiency in infection prevention and control was identified when two nurses failed to properly disinfect a glucometer used for a resident's blood glucose testing. The facility's policy required disinfection before and after use but lacked specific instructions. Observations showed that one nurse did not disinfect the glucometer after use, while another reused a disinfectant wipe. Interviews revealed inconsistencies in the understanding of the disinfection process, contributing to the deficiency.
A facility failed to maintain the privacy of a resident's medical records when a computer screen on a medication cart was left open and unattended, displaying sensitive information. Nurse #1 left the cart twice without activating the privacy screen, exposing the resident's MAR. Interviews confirmed the expectation to use the privacy screen to protect resident information.
Failure to Notify Physician of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to notify physicians in a timely manner regarding significant changes in condition for multiple residents, including the development of new pressure ulcers, a diabetic foot ulcer, and significant weight loss. In one case, a resident with a history of cerebral vascular accident and diabetes developed a pressure ulcer on her right heel, which was first observed by a nurse aide and nurse, but the physician was not notified until several weeks later when the wound had progressed to an unstageable ulcer with black eschar and foul odor. The wound nurse and medical director confirmed that they were not made aware of the wound until much later, and there was no documentation of earlier physician notification in the medical record. Another resident with vascular dementia and hemiparesis was found to have an unstageable open area on the left heel by the wound nurse, who treated the wound with standing orders and notified the wound nurse practitioner the following day. However, the resident's nurse practitioner and medical director were not notified of the new wound or subsequent lab results, and both stated they should have been informed to initiate appropriate interventions. Similarly, a resident with dementia and malnutrition experienced significant weight loss, but the physician was not notified promptly. The assistant director of nursing acknowledged responsibility for notifying the physician but admitted the notification was delayed due to waiting for a reweight and being busy with other tasks. Additionally, a resident with multiple sclerosis and hemiplegia reported a stage II pressure ulcer to the back of his thigh, which was documented and treated by a nurse without notifying the physician. The nurse believed the process was to enter a treatment order and document in the acute book, but not to notify the provider directly. The assistant director of nursing, nurse practitioner, and medical director all confirmed that the physician should have been notified of the new wound. These failures to notify the physician of significant changes in condition affected all four residents reviewed for notification.
Insufficient Staffing Leads to Missed ADL Care and Delayed Wound Treatment
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of residents, resulting in inadequate provision of activities of daily living (ADL) care, delayed and incomplete wound assessments, and insufficient medical treatment for pressure ulcers and diabetic care. Observations, record reviews, and interviews revealed that dependent residents did not consistently receive showers, and staff were frequently pulled from their assigned duties to cover staffing shortages, leading to missed care tasks. For example, shower team nursing assistants were reassigned to floor duties, resulting in multiple days when no showers were provided to residents. The facility also failed to obtain timely treatment orders and conduct routine assessments for residents with pressure ulcers. In several cases, pressure ulcers were identified but not promptly assessed or treated, leading to worsening conditions. One resident's pressure ulcer progressed to an unstageable wound with black eschar and foul odor due to delayed assessment and treatment. Another resident developed a stage 2 pressure ulcer that was not measured or reassessed after the initial treatment order expired, and no further treatment orders were obtained. Additionally, head-to-toe skin assessments were not completed accurately, failing to document the location, type, and measurements of wounds. Interviews with the Wound Nurse and administrative staff confirmed that staffing shortages significantly impacted the ability to provide consistent wound care and complete necessary documentation. The Wound Nurse reported being frequently reassigned to hall duties, making it difficult to monitor and treat wounds regularly. Administrative staff acknowledged that showers, wound treatments, and assessments were not being completed as required due to ongoing staffing challenges, including staff on leave and reduced availability.
Failure to Timely Assess, Identify, and Treat Resident Wound Infection
Penalty
Summary
The facility failed to provide appropriate skin assessments, timely identification of a new wound, and necessary medical treatment for a resident with significant comorbidities, including vascular dementia, hemiparesis, and hemiplegia. The resident was admitted with severe cognitive impairment and was care planned for comfort measures, with interventions to monitor and report changes in skin condition. Despite these interventions, there were no weekly skin assessments documented, and the process for skin checks relied on shower team observations rather than scheduled nursing assessments. A new wound on the resident's left heel was first noted as a red area by a nurse aide during a shower, but this information was not effectively communicated or documented by the assigned nurse. The wound was later identified as an open, unstageable area by the Wound Nurse, who treated it according to standing orders and notified the Wound Nurse Practitioner the following day. The Wound Nurse Practitioner found the wound to be deep, necrotic, and likely of diabetic etiology, ordering a wound culture, labs, and x-ray. However, there was a breakdown in communication regarding the results of the wound culture and sensitivity, which showed infection. The Wound Nurse Practitioner was incorrectly informed that the culture was negative and was not provided with the actual results, delaying the initiation of antibiotic therapy. Further interviews revealed that the NP and Medical Director were not notified of the new heel wound or the positive culture results in a timely manner. The Wound Nurse stated that lab results were faxed to providers only after all results were received, and the DON confirmed that the Wound Nurse Practitioner should have been shown the positive culture results during her visit. This lack of communication and failure to follow up on lab results led to a delay in the resident receiving appropriate antibiotic treatment for the infected wound.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In the first case, a resident with a history of cerebral vascular accident and diabetes mellitus was admitted without pressure ulcers and was care planned for risk of impaired skin integrity. Despite this, no skin assessments were documented from admission onward. When a pressure ulcer was first identified on the resident’s right heel, there was no documented assessment or treatment order, and the wound was not reported to the medical director. The wound worsened over several days, eventually becoming unstageable with black eschar and foul odor before appropriate treatment and assessment were initiated. In the second case, another resident with multiple sclerosis and hemiplegia was identified as being at risk for pressure ulcers but did not receive routine skin assessments. When a stage 2 pressure ulcer was found on the back of the resident’s right thigh, the initial wound was not measured until several days later, and there was no ongoing assessment or documentation after the initial measurement. The treatment order for the wound was only in place for seven days and was not renewed, leaving the wound without further treatment orders or follow-up. The wound care nurse was not aware of the wound, and the wound was not followed by the wound care provider. Both cases revealed a lack of routine and systematic skin assessments by nursing staff, reliance on nurse aides to report skin issues, and inconsistent use of wound care standing orders. There was also a lack of communication and documentation regarding new wounds, failure to notify providers in a timely manner, and inadequate follow-up and monitoring of existing wounds. These deficiencies resulted in pressure ulcers going untreated for extended periods and worsening in severity.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall interventions for a resident with a history of repeated falls and cognitive impairment. One resident, who had diagnoses including hemiplegia, hemiparesis, muscle weakness, and a history of stroke, experienced 12 falls over a six-month period. On one occasion, the resident was left unsupervised in the bathroom after being assisted onto the toilet by an occupational therapy assistant (OTA). The OTA placed the call light in the resident's hand and verbally instructed her to call for assistance when ready, then notified a nursing assistant (NA) outside the room. However, the assigned NA was not aware the resident was in the bathroom, and the resident attempted to transfer herself, resulting in a fall and a left ankle fracture. Staff interviews revealed inconsistent understanding of the resident's supervision needs, and documentation did not reflect the resident's fall risk accurately on the MDS assessment. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident with Alzheimer's dementia who was at risk for elopement. This resident exited the facility unsupervised on two separate occasions. In the first incident, the resident was able to leave the building when a receptionist opened the door for visitors, and staff were unaware of her absence until she was observed outside. There was no clear system in place to identify elopement risk residents to all staff, and the incident was not documented in the facility's incident log. In the second incident, the resident was again found outside the building by a receptionist, and staff were unable to state when the resident was last observed on the unit. The care plan for this resident included frequent checks and ensuring hallway doors were alarmed, but these interventions were not effectively implemented. Interviews with staff, including nurses, nursing assistants, and administrative personnel, revealed gaps in communication and supervision practices. There was a lack of clear documentation and investigation of the incidents, and staff were often unaware of the residents' whereabouts or supervision needs at the time of the events. The facility's failure to maintain a safe environment and provide adequate supervision resulted in preventable accidents, including a fall with injury and two elopement incidents involving residents with known risks.
Failure to Resolve and Communicate Actions on Repeated Resident Council Concerns
Penalty
Summary
The facility failed to adequately resolve and communicate its efforts to address repeated concerns raised by residents during Resident Council meetings over an eight-month period. Resident Council minutes consistently documented complaints regarding certified nursing assistants (NAs) using cell phones while working, slow response times to call bells—particularly on the second shift—and the early timing of ice distribution, which disturbed residents before breakfast. Despite these recurring issues being noted in the meeting minutes, the facility's documented responses were largely repetitive, indicating that concerns had been addressed, were being monitored, or would be discussed with staff, without evidence of effective resolution. During interviews, multiple residents expressed ongoing dissatisfaction, stating that their concerns were not taken seriously and that the facility's responses were unchanged from month to month. The Activity Director confirmed that the same issues were repeatedly brought up and that residents were disappointed with the lack of satisfactory resolution. The Administrator acknowledged the presence of cameras and stated that no staff had been identified using cell phones during care or delaying call light responses, but admitted to not thoroughly documenting or investigating the residents' concerns. The deficiency centers on the facility's failure to resolve and communicate actions taken regarding persistent resident complaints, as required by regulations supporting resident rights to organize and participate in resident/family groups.
Failure to Provide Written Information on Advance Directives at Admission
Penalty
Summary
The facility failed to provide residents and their representatives with written information regarding advance directives and the right to accept or refuse medical or surgical treatment, as required by their own policy and federal regulations. Record review and interviews revealed that, for two residents, there was no evidence of an advance directive checklist, signed acknowledgment of receipt, or any documentation that written information about advance directives was provided at admission. The facility's admission packet did not include written materials about advance directives or the right to accept or refuse treatment, and there was no process in place to ensure residents or their representatives received or acknowledged this information. Interviews with the residents, their representatives, the Social Worker (who also served as the admission coordinator), and the Administrator confirmed that the facility's practice was to discuss only the Medical Order for Scope of Treatment (MOST) form, without providing any written literature about advance directives or the right to refuse care. Both residents and their representatives were unaware of what an advance directive was and did not recall receiving any information on the topic. The Social Worker and Administrator acknowledged that the facility did not include written information about advance directives in the admission process and were unaware of the requirement to do so.
Failure to Provide Scheduled Showers Due to Staffing and Process Gaps
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically showers, to dependent residents as required. Two residents with significant physical impairments and care needs did not receive scheduled showers on multiple occasions. Documentation showed missed showers on several scheduled days, and both residents confirmed in interviews that they had not been receiving showers regularly. One resident reported that showers were often missed due to staff shortages, and that make-up showers were not provided if a scheduled shower was missed. Observations noted that while there was no body odor, one resident had greasy, uncombed hair, indicating a lack of personal hygiene care. Interviews with the shower team nurse aides (NAs) revealed that they were frequently pulled from their shower duties to work on the floor when the facility was short-staffed. The NAs stated that when they were reassigned, showers were not given by floor staff, and missed showers were not rescheduled. The shower team reported that even when not pulled, the workload was too high for two NAs to complete all scheduled showers, and they had requested additional help from facility leadership. Other staff, including the unit clerk and additional NAs, confirmed that showers were not provided when the shower team was reassigned, and that this was a frequent occurrence. Facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, acknowledged that there was no process in place to ensure residents received showers when the shower team was pulled to the floor. The ADON was aware that residents did not receive showers in these situations and that some residents had complained. The DON and Administrator were not fully aware of the extent of the missed showers until the issue was brought to their attention. The lack of a contingency plan and insufficient staffing directly led to the failure to provide required ADL care for dependent residents.
Confidential Medical Information Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when confidential medical information was left unattended and visible on top of a medication cart in the 500 hall. The narcotic book was open to a resident's narcotic sheet, displaying the resident's name, medication name, directions for use, frequency of use, indication, and remaining count. Additionally, two empty medication cards for two other residents, including their names, medication names, and usage directions, were also left exposed. During this time, no nurse was present at the cart, and two staff members along with one resident walked by, making the information accessible to unauthorized individuals. When a nurse returned to the cart, she acknowledged that she had forgotten to close the narcotic book and recognized that leaving the information visible was a violation of privacy and confidentiality. The Director of Nursing, in the presence of the Administrator, confirmed that this was a HIPAA violation and stated that staff receive education on HIPAA requirements during orientation and annually. The incident was identified through record review, observation, and staff interviews.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse policy and procedures in the areas of prevention, protection, reporting, and investigation following an incident in which a nurse aide witnessed another staff member physically abuse a resident with dementia during incontinence care. The incident involved the staff member grabbing both of the resident's wrists and slapping the resident's hand after the resident resisted care. The witnessing nurse aide did not immediately intervene or report the abuse, instead waiting until the end of her shift to inform the nurse on duty. As a result, the accused staff member continued to provide care and remained on the floor for the remainder of her shift. Upon being informed of the incident at shift change, the nurse and another nurse present did not immediately notify administration or take steps to protect the resident or other residents from further potential abuse. The nurse checked on the resident but did not observe any marks and decided, along with the oncoming nurse, to report the incident to management the following morning. The delay in reporting meant that the accused staff member was not suspended or removed from resident care until after the next shift, contrary to facility policy which required immediate reporting and protection of residents. The facility's investigation into the abuse allegation was incomplete, as it did not include interviews or assessments of other residents who may have received care from the accused staff member during the remainder of her shift. The investigation focused only on the direct witnesses and the accused, and did not determine whether other residents were affected. The facility's own policy required immediate reporting, collection of statements from all witnesses, and assessment of all potentially affected residents, but these steps were not followed.
Inaccurate MDS Coding for PASRR Level II and Pressure Wound
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents in the areas of Preadmission Screening and Resident Review (PASRR) Level II and pressure wounds. For one resident with a diagnosis of bipolar disorder, the electronic health record contained a PASRR Level II determination, but the annual MDS was incorrectly coded as Level I. Staff interviews confirmed this was a human error. Similarly, another resident with bipolar disorder had a PASRR Level II determination in the health record, but the annual MDS was also incorrectly coded as Level I, which staff attributed to a coding error. Additionally, a resident with vascular dementia and hemiparesis was incorrectly coded on the quarterly MDS as having a stage 1 pressure ulcer, even though the pressure ulcer developed after the assessment date. Staff interviews confirmed that the resident did not have a pressure wound at the time of the MDS assessment and that the coding was an input error. The administrator acknowledged that the MDS should accurately reflect the resident's conditions and that these were errors.
Failure to Revise Care Plan After Development of Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident who developed a pressure ulcer after admission. The resident, who had a history of cerebral vascular accident and diabetes mellitus, was admitted without pressure ulcers and was assessed as having severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The initial care plan identified the resident as being at risk for impaired skin integrity and included interventions such as frequent turning, skin monitoring, and prompt notification of nursing staff for any open areas. However, when an unstageable wound with black eschar and foul odor was discovered on the resident's right heel, the care plan was not updated to reflect this new development. Medical records showed that the wound nurse documented the new pressure ulcer and obtained treatment orders, including antibiotics, an X-ray, and a wound consult. Despite this, there was no evidence that the care plan was revised to address the new pressure ulcer. Interviews with the MDS nurse revealed that she was informed of the new wound during a clinical meeting but failed to update the care plan upon returning to her office. The administrator confirmed that it was the MDS nurse's responsibility to revise care plans promptly for new developments such as pressure ulcers.
Failure to Timely Reweigh and Report Significant Weight Loss
Penalty
Summary
The facility failed to act promptly on the Registered Dietitian's (RD) recommendation to reweigh a resident after a significant weight loss was identified. The RD had recommended a reweight and an increase in nutritional supplements after noting a 13.6% weight loss in one month. Although the diet order was revised to increase calories and supplement volume, the reweight was not performed until several days later, and the result was neither documented in the medical record nor reported to nursing management until more than two weeks after it was obtained. This delay prevented timely recognition and intervention for the resident's ongoing weight loss. The resident involved had multiple diagnoses, including dementia, hypothyroidism, nutritional deficiency, and protein-calorie malnutrition. She was noted to have severe cognitive impairment and required setup and clean-up assistance with eating. Despite her significant weight loss and poor oral intake, there was no evidence that her nutritional status or lack of eating was discussed by the interdisciplinary team or reported to the physician. During meal observation, the resident did not consume any food independently, and staff did not provide cues or encouragement to eat, even though she typically required such assistance. Interviews with facility staff revealed lapses in communication and follow-through regarding the resident's weight monitoring. The Assistant Director of Nursing (ADON) acknowledged responsibility for ensuring weights were completed but did not follow up in a timely manner. The Unit Clerk obtained the reweight but failed to enter it into the medical record or notify the ADON. The RD and Medical Director were not informed of the significant weight loss, and the Medical Director stated he would have taken further action if notified. The Director of Nursing (DON) and Administrator both indicated that reweights and documentation should occur promptly, but this did not happen in this case.
Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Safety Measures
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for three residents requiring oxygen therapy. For two residents with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and respiratory failure, observations revealed that the oxygen concentrator filters in their rooms contained significant debris build-up, described as fluffy, crumbly, and light brown in color. Staff interviews confirmed that the filters were not being cleaned daily as required, and there was confusion among staff regarding the cleaning schedule and responsibilities. Additionally, the oxygen tubing was not consistently labeled to indicate when it was last changed, making it difficult to track compliance with weekly tubing changes. Further deficiencies were noted in the lack of appropriate oxygen in use signage on the entrances to the rooms of all three residents receiving oxygen therapy. Observations on multiple occasions confirmed that the required signage was missing, and staff interviews revealed uncertainty about who was responsible for placing the signs. The Director of Nursing stated that signage should be present on or near the resident's door whenever oxygen is in use, but this was not being consistently implemented. Additional safety concerns were observed regarding the handling and storage of oxygen tanks. In one instance, an oxygen tank was found stored upright on the floor of a resident's room without being secured in a holder, and staff were unable to identify who had placed it there. In another instance, a nurse aide was observed transporting a full oxygen tank by carrying it in her arms rather than using a cart or secure holder, contrary to facility expectations. The aide later acknowledged that a cart was available for this purpose but was unsure of its location at the time.
Failure to Ensure Nurse Aide Competency and Training Enrollment
Penalty
Summary
The facility failed to ensure that a staff member working as a nurse aide (NA) met the minimum competency requirements as outlined by state and federal regulations. Specifically, one staff member was hired to work full-time as an NA without having completed a state-approved nurse aide training program, passed a certification exam, or undergone a competency evaluation prior to providing direct care to residents. Record review showed that this staff member was not enrolled in a state-approved training program at the time of hire and had not completed a skills competency checklist. The Director of Nursing (DON) confirmed that the staff member had only recently attempted to enroll in a hybrid online program but was advised to attend an in-person program at a later date. Despite this, the staff member was scheduled and assigned NA tasks over multiple shifts. Interviews with the Administrator and DON revealed that the facility did not have an in-house state-approved NA training program and routinely hired staff to work as NAs before enrolling them in external training programs. The Administrator stated that staff were allowed to perform all NA duties during their first four months of employment, regardless of their enrollment status in a training program. This practice continued after the expiration of a pandemic-related waiver, under the mistaken belief that staff could still work for four months before certification as long as they eventually enrolled in a program. The facility's approach did not comply with the requirement that staff must be actively participating in a state-approved NA program during the four-month grace period.
Improper Labeling and Storage of Medications on Medication Carts
Penalty
Summary
Surveyors observed that drugs and biologicals were not properly labeled or stored in accordance with professional standards on two medication carts. On the 200-hall medication cart, 13 loose pills of various shapes, colors, and sizes were found in the bottom of the drawers. Additionally, open and undated boxes of budesonide and DuoNeb solutions were present, despite manufacturer guidelines requiring budesonide vials to be used within two weeks of opening the foil pouch and DuoNeb vials within seven days. The nurse responsible for the cart was unaware of these guidelines and had not cleaned the cart during her shift. On the 500-hall medication cart, four loose albuterol sulfate solution vials and an open, undated box of DuoNeb solutions were found in the drawer. Manufacturer instructions specify that albuterol sulfate should be stored in the foil pouch to protect from light, and DuoNeb vials should be used within seven days of opening. The nurse assigned to this cart also had not cleaned the cart and was unaware of the storage and labeling requirements. The DON stated that while each nurse is responsible for keeping carts clean, the weekend supervisor is tasked with ensuring medication carts are organized and that medications are properly stored and labeled.
Failure to Notify Provider of Positive Wound Culture Result Delays Antibiotic Treatment
Penalty
Summary
A deficiency occurred when the facility failed to notify the Wound Provider of a positive wound culture and sensitivity laboratory result for a resident with vascular dementia, hemiparesis, and hemiplegia following a stroke. The resident was admitted with multiple wounds, including an unstageable left heel wound suspected to be of diabetic origin. The Wound Provider evaluated the wound and ordered a culture and sensitivity due to suspicion of infection. The laboratory report, completed and sent to the facility, indicated the presence of moderate proteus mirabilis and scant staphylococcus aureus. Despite the availability of the positive lab results, the Wound Provider was not informed of the findings when she visited the facility. Instead, she was incorrectly told by the Wound Nurse that the culture was negative, and she did not have access to the actual results. The Nurse Practitioner (NP) was also not notified of the laboratory results or the Wound Provider's treatment orders. The NP only became aware of the positive culture several days later, at which point antibiotics were ordered for the resident's infected heel wound. Interviews with facility staff, including the Wound Nurse, NP, and DON, revealed lapses in communication and delays in providing laboratory results to the appropriate providers. The DON acknowledged that the Wound Provider should have been shown the results during her visit, and the Medical Director confirmed that the delay resulted in the resident missing at least one day of antibiotic treatment. The Wound Nurse admitted to not having seen the results before reporting them as negative, contributing to the delay in appropriate care.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its own Hand Hygiene and Enhanced Barrier Precautions (EBP) policies and procedures during wound care for two residents. Observations revealed that the Wound Nurse did not don a gown, change gloves, or perform hand hygiene at required points during wound care procedures. Specifically, after removing soiled dressings and after cleansing wounds, the Wound Nurse did not change gloves or sanitize hands before applying new dressings. These lapses were observed during wound care for a resident with an unstageable right heel pressure ulcer and another resident with a diabetic foot ulcer. The Wound Nurse acknowledged during interviews that she did not follow proper glove changing and hand hygiene protocols, stating she "just forgot" to perform these steps. She also did not wear a gown during the procedures, explaining that she had questioned the need for EBP with the Assistant Director of Nursing (ADON), who advised that EBP was not required for these residents. The nurse was unaware that EBP should be used for open, draining wounds regardless of their chronicity or expected healing time. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a misunderstanding of CDC guidelines regarding EBP. Both believed that EBP was only necessary for wounds present for six months or longer, and therefore did not implement EBP for the residents in question. The IP and DON were informed during the survey that EBP should be applied to any open, draining wounds, not just chronic wounds, and acknowledged the need to reevaluate their practices.
Failure to Maintain Clean and Safe Laundry Equipment
Penalty
Summary
Surveyors observed that two dryers in the facility's laundry room, located in a separate building, contained significant accumulations of dark-colored dust balls and thick sheets of lint in the lint traps. When the dryer doors were opened, lint approximately 1/4 inch thick fell from the traps. Staff interviews revealed that the laundry aide, who worked first shift, claimed to clean the dryer vents and filters every shift but could not explain the presence of the lint and dust buildup. The Environmental Services Supervisor stated that dryer vents and lint traps should be cleaned daily, but acknowledged that the observed buildup indicated the current cleaning frequency was insufficient.
Failure to Ensure Dignified Meal Service and Proper Feeding Assistance
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination during meal service for two residents. One resident with moderate cognitive impairment and a history of dysphagia, diabetes, and malnutrition was not served her meal at the same time as others at her dining table. Despite raising her hand and expressing hunger multiple times, her meal was delayed by nearly 20 minutes due to disorganization in the kitchen following a staff call-out and late arrival. The resident's meal was mistakenly sent to her floor instead of the dining room, and she only received her food after staff were alerted to the error. Another resident, who had severe cognitive impairment and required assistance with eating due to Alzheimer's dementia and dysphagia, was observed being fed by a nursing assistant who stood at the side of the bed rather than sitting at eye level, as required. Although a chair was available in the room, the nursing assistant did not use it. Both the nursing assistant and the facility administrator confirmed that staff are expected to sit when feeding residents, but this protocol was not followed during the observed meal.
Resident Physically Abused by Staff During Care
Penalty
Summary
A resident with severe cognitive impairment, dementia, and anxiety, who was dependent on staff for activities of daily living and personal hygiene, was subjected to physical abuse by a staff member during incontinence care. The resident was known to be combative and sometimes refused care, as documented in her care plan, which included interventions such as explaining procedures, using a calm approach, and providing reassurance. During an episode of care, the resident became agitated, verbally resisted, and attempted to push staff hands away. While two nurse aides were providing care, one staff member became angry at the resident's resistance, grabbed both of the resident's wrists, yelled at her, and slapped her on the hand with an open hand. The incident was witnessed by the other aide, who reported that the resident appeared startled and subsequently exhibited fearful and suspicious behavior towards staff. The staff member involved admitted to hitting the resident, stating it was an instinctive reaction after being slapped by the resident. The incident was not reported to the Director of Nursing until the following morning, after being relayed through multiple staff members. The resident was observed to be fearful during subsequent care, asking staff not to hurt her. The facility's investigation substantiated the abuse, confirming that the staff member had physically abused the resident during care.
Failure to Accurately Post and Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that Nurse Staffing Information was posted in a prominent and readily accessible location for residents, staff, and visitors. Observations revealed that the staffing sheets were placed flat on the counter of the receptionist desk in the front lobby, requiring individuals to stand over the desk and look down to view them. Interviews with the receptionist and the administrator confirmed that this had been the standard practice, and neither was aware that this did not meet regulatory requirements for accessibility. Additionally, the facility did not accurately complete the Nurse Staffing Information sheets. On multiple days, the resident census section was either left blank or included both skilled nursing and assisted living residents, rather than only the skilled nursing census as required. The administrator acknowledged that the census for the entire facility had been included for an extended period and was unaware that this was incorrect until reviewing the regulations during the survey. There were also discrepancies between the posted Nurse Staffing Information sheets and the actual nursing assignment sheets. The posted sheets often listed incorrect numbers and hours for RNs, LPNs, NAs, and did not include Temporary Nurse Aides (TNAs) who were scheduled to work. The administrator stated she was not aware that the posted information needed to reflect absences due to illness or call-outs, but recognized the requirement after reviewing the regulations. These inaccuracies were observed across all reviewed days.
Deficient Sanitation in Laundry Rooms and Medication Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in both laundry rooms and in the handling of medication equipment. In the laundry room located in a separate building, there were strings of dust hanging from a dryer, dust accumulation on the tops of washers, and a thick layer of dust on baseboard trim stored above a worktable where clean linens and residents' personal clothing were placed. The Environmental Services Supervisor confirmed that the laundry room should be cleaned daily, including dusting equipment, and acknowledged that the area was being used for storage of old furniture and personal items, which should not be near clean laundry. Inside the facility, a housekeeping cart was stored next to a rack of residents' clean clothing, and the cart was not deep cleaned daily. The Environmental Services Supervisor stated that the residents' clothing would need to be rewashed and covered to prevent contamination. Additionally, a pill crusher on the 100-hall medication cart was found to have a dried light brown liquid substance and dark brown debris embedded in its crevices, indicating it had not been cleaned in a long time. Both the Wound Nurse and another nurse assigned to the 100-hall medication cart confirmed that nurses are responsible for cleaning the pill crushers and medication carts, and both acknowledged the pill crusher was visibly soiled and needed cleaning. The DON stated that cleaning the pill crusher was part of the medication cart cleaning process and should be done by the weekend supervisor.
Resident Fall Due to Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to provide a safe environment for a resident, resulting in a fall and injury. The resident, who had functional quadriplegia, dementia, and a traumatic brain injury, was at risk for falls and required maximum assistance for personal care. During a bed bath, the resident fell from the bed, striking a chair and then the floor, which resulted in a fractured right femur. The care plan for the resident included maintaining a clutter-free environment, keeping the bed in a low and locked position, and using M-rails for mobility and transfers. On the day of the incident, a nursing aide was providing a bed bath to the resident, who was resistant to care and exhibited behaviors such as yelling and attempting to hit. The aide continued with the bed bath despite the resident's resistance. The resident was positioned on her left side, holding onto the bed railing with her right hand, and was left unattended when the aide went to rinse a washcloth. During this time, the resident lowered her right leg, causing her to fall off the bed. The aide was unable to prevent the fall as the resident was wet and slipped from her grip. The incident report and interviews with staff indicated that the resident was screaming in pain and was resistant to being assessed for injuries. The medical director, who was present in the facility, ordered pain and anxiety medication and had the resident sent to the emergency room, where a fractured femur was confirmed. The director of nursing noted that the aide should not have left the resident unattended on her side near the edge of the bed, which contributed to the fall and subsequent injury.
Inadequate Training on Glucometer Disinfection
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the disinfection of glucometers, as evidenced by observations and interviews with five out of six nursing staff members. Nurse #2 was observed returning a glucometer to the medication cart without disinfecting it after use, and she admitted to not receiving training on glucometer disinfection since being rehired. Similarly, Nurse #3 used a previously used disinfectant wipe to clean the glucometer, believing it was still effective. Both nurses' orientation skills checklists lacked specific education on glucometer disinfection. Nurses #4 and #5, along with the Weekend Nurse Supervisor, also demonstrated a lack of proper knowledge regarding glucometer disinfection. Nurse #4 used an alcohol prep pad for cleaning, which is ineffective against bloodborne pathogens, and could not recall receiving specific training on the process. Nurse #5 similarly used an alcohol wipe, citing a lack of education on the correct procedure. The Weekend Nurse Supervisor, responsible for completing the skills checklist, did not specifically review glucometer disinfection unless prompted by the nurse, despite knowing the correct procedure. The Staff Development Coordinator (SDC) and Director of Nursing (DON) acknowledged the absence of specific training on glucometer disinfection in the orientation skills checklist. The SDC conducted an in-service on glucometer cleaning, but it was not mandatory, and several nurses, including the Weekend Nurse Supervisor, did not attend. The DON and Assistant Administrator admitted that the facility lacked a specific policy on glucometer disinfection, and the skills checklist did not explicitly cover this area, leading to inconsistent training and understanding among the nursing staff.
Medication Security Lapses in LTC Facility
Penalty
Summary
The facility failed to properly secure medications, as evidenced by two separate incidents. In the first incident, an antifungal powder prescribed for a resident with dementia was found unsecured at the resident's bedside. The resident, who had moderate cognitive impairment and required assistance with daily activities, did not have a physician's order for self-administration of the medication. The antifungal powder was supposed to be stored in the treatment cart, but it was left on the bedside table, and neither the resident nor the wound nurse knew how long it had been there or which nurse had left it. In the second incident, a medication cart in the 600-hall was observed unattended and unlocked on two occasions. The cart was left unlocked while staff were distributing lunch trays, and Nurse #1 admitted to forgetting to lock it. The DON confirmed that the medication cart should have been locked when unattended to prevent unauthorized access. The Assistant Administrator also acknowledged that the cart should have been locked when Nurse #1 left it.
Failure to Provide SNF-ABN to Resident
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to a resident prior to discharge from Medicare Part A skilled services. The resident, who was admitted with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and dementia, was severely cognitively impaired according to the most recent Minimum Data Set assessment. Despite being informed that Medicare Part A coverage for skilled services would end on a specific date, the resident remained in the facility without receiving the required SNF-ABN. The Business Office Manager did not issue the SNF-ABN, mistakenly believing it was only necessary for managed care residents. She had been trained to issue a Notice of Medicare Non-Coverage (NOMNC) instead, which she did. The Assistant Administrator acknowledged awareness that a SNF-ABN should be issued for residents discharged from Medicare Part A services who remain in the facility, indicating a lapse in the facility's process for ensuring proper notification.
Missed Antibiotic Doses Due to Pharmacy Delivery Delay
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident, resulting in two missed doses of an antibiotic. The resident, who was admitted with conditions including hypoxemia, shortness of breath, and COPD, had an active order for Doxycycline to be administered twice daily. The order was entered into the system on the afternoon of 9/2/24, but the first dose was not administered until the evening of 9/3/24. This delay was due to the medication not being available in the facility's emergency backup kit and the pharmacy being closed for a holiday. Nurse #4, who was on duty when the order was placed, did not contact the pharmacy, assuming the medication would arrive with the next delivery. Similarly, Nurse #7, who was on duty the following day, also did not contact the pharmacy, expecting the medication to arrive with the afternoon delivery. The pharmacy technician confirmed that the pharmacy was closed on 9/2/24 but had an on-call pharmacist available. The Doxycycline order was received by the pharmacy on 9/2/24, but due to the holiday closure, it was not delivered until the afternoon of 9/3/24. The Director of Nursing and Assistant Administrator acknowledged that the nurses should have contacted the pharmacy when the medication was not found in the emergency kit.
Failure to Administer Antibiotic Timely
Penalty
Summary
The facility failed to administer an antibiotic as ordered for a resident, leading to a significant medication error. The resident, who was admitted with diagnoses including hypoxemia, shortness of breath, and COPD, had an active order for Doxycycline to be administered twice daily. However, the first dose scheduled for the evening of the order date was not administered, and the subsequent morning dose was also missed. The first dose was only given more than 24 hours after the order was placed. The delay in administering the antibiotic was due to several factors. Nurse #4, who was responsible for the resident on the day the order was placed, did not find the medication in the emergency kit and assumed it would arrive with the next pharmacy delivery. Similarly, Nurse #7, who was on duty the following day, also did not receive the medication and did not contact the pharmacy, assuming it would arrive with the regular delivery. Both nurses were unaware of the pharmacy's holiday schedule, which had been communicated in advance, indicating altered delivery times and the availability of an on-call pharmacist for urgent needs. The Assistant Administrator, who entered the order, did not check the emergency medication kit to ensure the availability of Doxycycline, which was not included in the kit. The pharmacy had been closed for a holiday, and although a memo had been posted about the closure and the procedure for obtaining medications, it was not acted upon. The Medical Director and Director of Nursing acknowledged that the delay in starting the antibiotic was too long, especially given the resident's condition, although the resident did not exhibit significant clinical symptoms at the time.
Deficiency in Glucometer Disinfection Protocol
Penalty
Summary
The facility failed to establish and implement a clear policy and procedure for the disinfection of glucometers, leading to a deficiency in infection prevention and control. Observations revealed that Nurse #2 and Nurse #3 did not properly disinfect a glucometer used for a resident's blood glucose testing. The facility's existing policy stated that each resident should have their own glucometer, which should be disinfected before and after use, but it did not specify the method for disinfection. Additionally, the facility lacked a separate policy specifically addressing glucometer disinfection. During the observations, Nurse #2 performed a blood glucose test for a resident without disinfecting the glucometer after use, despite having disinfectant wipes available on the medication cart. Nurse #2 believed that disinfection was only necessary before use. Similarly, Nurse #3 used a disinfectant wipe before the test but reused the same wipe afterward, contrary to the proper procedure of using a new wipe for disinfection. Both nurses stored the glucometer in the medication cart, which was a common practice in the facility, although it was intended for individual use and not shared among residents. Interviews with the Staff Development Coordinator, Director of Nursing, and Assistant Administrator highlighted inconsistencies in the understanding and implementation of the disinfection process. The Staff Development Coordinator described a two-step disinfection process, which was not followed by the nurses. The Director of Nursing and Assistant Administrator both emphasized the importance of using a new EPA-approved disinfectant wipe before and after each use to prevent blood-borne pathogen transmission. However, the facility's policy did not provide clear instructions on the disinfection process, contributing to the observed deficiency.
Failure to Maintain Privacy of Resident Records
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records when a computer screen on a medication cart was left open and unattended, displaying sensitive resident information. During an observation, the 600-hall medication cart was found unattended with the computer screen displaying a resident's Medication Administration Record (MAR), which included the resident's picture, name, date of birth, room number, record number, special instructions, allergies, current vital signs, and medications. Staff were observed distributing lunch trays in the hallway at the time. Nurse #1 was responsible for the medication cart and returned to it after a few minutes, placing the privacy screen on the computer. However, shortly after, Nurse #1 left the cart again without activating the privacy screen, leaving the resident's information exposed once more. Interviews with Nurse #1, the Director of Nursing (DON), and the Assistant Administrator confirmed that the privacy screen should have been used to protect resident information when the nurse was not present at the cart. Nurse #1 acknowledged forgetting to activate the privacy screen, and both the DON and Assistant Administrator reiterated the importance of using the privacy screen to prevent unauthorized access to resident information.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 7 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Givens Health Center | 5.3 mi | ★★★★★ | 1 | 0 |
| Swannanoa Valley Health And Rehabilitation | 6 mi | ★★★★★ | 4 | 0 |
| Biltmore Haven Nursing And Rehabilitation | 6.1 mi | ★★★★★ | 2 | 2 |
| Deerfield Episcopal Retirement | 6.1 mi | ★★★★★ | 1 | 0 |
| Fletcher Rehabilitation And Healthcare Center | 6.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.