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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairview Manor during CMS and state inspections, most recent first.
A resident with diabetes, poor appetite, and impaired nutritional status had orders for AM and HS blood glucose checks and a care plan calling for monitoring for hyper/hypoglycemia and accu-checks, but the MAR showed no evidence the monitoring was done for 22 days. The resident became lethargic, a family member learned the blood sugars had not been checked, and the blood sugar was 581. The resident was then sent out and admitted to the ICU with HHS, urosepsis, hyperglycemia, hypernatremia, and hypercalcemia; the DON confirmed the care plan interventions were not implemented.
Failure to follow ordered blood glucose monitoring led to hospitalization for a resident with diabetes and poor appetite. The resident’s physician ordered AM and HS blood sugar checks, but the MAR lacked evidence the checks were completed, and an LPN told family the blood sugars were not being checked. When a blood sugar was finally obtained, it was 581, and the resident was later admitted to the ICU with HHS, Urosepsis, hyperglycemia, hypernatremia, and hypercalcemia.
Failure to Communicate Clinical Information During Hospital Transfers: The facility did not ensure that necessary clinical information was communicated to the receiving provider when several residents were transferred to the hospital. Records for multiple residents with conditions such as HF, AFib, diabetes, anemia, GERD, HTN, encephalopathy, respiratory failure, sepsis, quadriplegia, and hyperlipidemia showed hospital transfer notes, but no evidence that the required information was sent at the time of transfer. The DON confirmed the missing documentation.
Failure to Provide Baseline Care Plan and Order Summary: The facility lacked evidence that written baseline care plan summaries and order summaries were provided to three residents and/or their representatives upon admission. The records for residents with diagnoses including lung cancer, depression, anemia, GERD, HTN, encephalopathy, respiratory failure, and sepsis did not show that the required care plan and physician order information for meds, diet, and therapy services was given, and the NHA and DON confirmed the missing documentation.
Failure to include residents in care plan meetings: Two residents, including one with COPD, GERD, and HTN and another with hemiparesis/hemiplegia related to cerebral infarction, DM, and HTN, did not recall being invited to or attending care plan meetings. Their records lacked evidence of routine resident and/or representative participation with multiple quarterly and annual MDS assessments, and a SW stated care plan meetings were not consistently held and were not scheduled with the MDS process.
A resident with a stroke history, malignant carcinoid tumor, and HTN had physician orders for PICC care and daily IV flushes, but the resident's person-centered care plan did not include an IV therapy plan with measurable objectives and timetables. The DON confirmed that the IV therapy care plan had not been developed.
A resident with DM, dementia, and HTN was identified as an elopement risk, but the care plan was not revised after the resident eloped. The NHA confirmed the care plan was not reviewed or updated following the event.
A resident with dementia, diabetes, and HTN eloped from a supervised area despite having a secure care device in place. Staff heard the alarm but did not see the resident inside or near the door, and the resident was later found outside in a parking lot after a caller reported someone in a wheelchair heading toward the road. The NHA confirmed staff did not properly supervise the resident or respond appropriately to the alarm with a head count and thorough outside search.
A resident with hemiparesis, hemiplegia related to CVA, DM, and HTN had an O2 order via nasal cannula or mask to keep sats at or above 90%. Staff observed the resident on O2 with the concentrator set at 2 lpm, but both side filters were covered with a large amount of gray fluffy substance. An LPN confirmed the filters were soiled and should be cleaned, despite a facility policy and MD order for weekly filter cleaning.
Medications were not properly dated when opened in the Main Medication Room and on the D-Wing med cart. An opened vial of Tubersol PPD in the refrigerator and an open Lantus insulin injector pen were both found without open dates, and staff could not determine their expiration dates. The DON and an LPN confirmed the missing dates.
Incomplete and inaccurate clinical record documentation: The facility failed to keep complete clinical records for two residents. One resident with stroke, cancer, and HTN had orders for a PICC and daily NS flushes, but the chart documented a right chest tunneled CVC instead. Another resident with DM, dementia, and HTN had an elopement event, but there was no documentation of the incident in the clinical record. The NHA and DON confirmed the documentation gaps.
The facility failed to meet professional standards of nursing care by allowing LPNs, without RN oversight, to assess residents who experienced falls, changes in condition, or device dislodgement that led to emergency hospital transfers. Multiple residents with complex medical histories, including diabetes, heart failure, COPD, stroke, kidney stones with drainage tubes, and infections, were evaluated and sent to the hospital based solely on LPN assessments, with no RN assessments documented in the clinical records. LPNs reported they were expected to assess newly admitted residents, those with injuries, and those with changes in condition, and to obtain provider orders for hospital transfer, often when no RN was available. The DON confirmed that these assessments were completed by LPNs alone and stated unawareness that RN assessments were required for residents with changes in condition, contrary to state nursing practice standards and the facility’s own job descriptions.
A resident with renal dialysis dependence, existing right foot wounds, stage 3 kidney disease, and gout returned from dialysis in a wheelchair and was later found with heavy bleeding and abrasions on four toes of the left foot, including tissue loss and a missing toenail, requiring pressure dressings and rewrapping when bleeding recurred. The resident reported that transport staff had bumped into a curb, while the contracted transport driver stated being unaware of any injury. Despite facility policy requiring interviews of the resident, alleged involved parties, and witnesses, written statements, analysis of evidence, and documentation of the investigation and conclusions, the NHA could not locate any investigation notes or interview documentation related to this injury of unknown origin.
A resident with hemiplegia, hemiparesis, and other conditions was transferred using a mechanical lift by only one nurse aide, despite facility education and physician orders requiring two staff for such transfers. Both the nurse aide and an LPN confirmed the two-person protocol was not followed during the observed transfer.
Multiple residents reported long delays in call bell responses, missed showers, unchanged bed linens, and cold meals due to insufficient nursing staff and staff inattentiveness, including frequent cell phone use and loud conversations in hallways. These issues led to unmet care needs and dissatisfaction with the care provided.
A resident with multiple medical conditions had conflicting documentation regarding life-sustaining treatment: the physician's order and care plan indicated Full Code status, while the signed POLST specified DNR. The DON confirmed these documents were not consistent and should have reflected the resident's advance directive wishes.
A resident with an indwelling catheter was incorrectly coded on the MDS as 'occasionally incontinent' and 'always incontinent' instead of 'not rated,' despite having the catheter throughout the assessment period. This error was confirmed by the RN Assessment Coordinator, who acknowledged the MDS did not accurately reflect the resident's continence status.
A resident was readmitted from the hospital with multiple diagnoses and began receiving hospice services from an outside agency, as documented in the clinical record. However, there was no physician's order for these hospice services, a fact confirmed by the DON during staff interview.
A resident with a PICC line and indwelling urinary catheter did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy and CDC guidelines. Observations revealed the absence of EBP signage and readily available PPE such as gowns and gloves in the resident's room, and the clinical record lacked a physician's order for EBP. The DON confirmed these deficiencies during an interview.
The facility failed to meet the required RN staffing levels, with shortages observed over a 14-day period. The deficiency was confirmed through staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the minimum RN ratios.
The facility failed to provide the services of an RN for at least 8 consecutive hours a day, 7 days a week, over a 21-day period. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home administrator, who acknowledged the absence of RN coverage for the required shifts.
A facility failed to maintain accurate documentation for a resident receiving enteral feeding and water flushes via a gastric tube. The MARs from January to May 2024 showed discrepancies, with documented intake often below the ordered amount, some entries left blank, and others marked incorrectly. The DON confirmed the incomplete and inaccurate documentation, violating professional standards.
Failure to Implement Ordered Blood Sugar Monitoring and Care Plan Interventions
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with diabetes and impaired nutritional status who required blood sugar monitoring. The resident was admitted with diagnoses including protein calorie malnutrition, diabetes mellitus, bladder cancer, dehydration, hypo-osmolality, hyponatremia, and hypokalemia. A pre-admission hospital note stated that glipizide was being held because of poor appetite and that Accu-Checks and a correction scale would be ordered, with insulin started if sugars were high. The admission physician order directed blood glucose checks in the morning and at bedtime, and the care plan dated 4/06/26 included monitoring for signs and symptoms of hyper/hypoglycemia and administering accu-checks as ordered. The April 2026 MAR lacked evidence that blood sugar monitoring twice daily was implemented, and as of 4/28/26, 22 days of accu-checks had not been completed. On 4/28/26, the resident was lethargic all day, and when a family member asked about blood sugars, the LPN stated they had not been checked; the blood sugar was then checked and was 581. The physician was notified and the family requested transfer for evaluation. The next day, the resident was admitted to the ICU with diagnoses of Hyperosmolar Hyperglycemic State, Urosepsis, Hyperglycemia, Hypernatremia, and hypercalcemia. The DON later confirmed that the care plan interventions for monitoring and accu-checks were not implemented, resulting in hospitalization and actual harm.
Failure to Follow Ordered Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice by not following a physician-ordered blood glucose monitoring schedule for Resident R1. Resident R1 was admitted with diagnoses including protein calorie malnutrition, diabetes mellitus, malignant neoplasm of the bladder, dehydration, hypo-osmolality, hyponatremia, and hypokalemia. The pre-admission hospital note stated that glipizide was being held because of poor appetite and that Accu-Checks and a correction scale would be ordered, with insulin started if sugars were high. The admission physician order directed blood glucose checks in the morning and at bedtime for diabetes, and the care plan included monitoring for signs and symptoms of hyper/hypoglycemia and administering accu-checks as ordered. The MAR for April 2026 lacked evidence that blood sugar monitoring was completed twice daily. Progress notes showed that on 4/28/26 Resident R1 was lethargic all day, and a family member asked about blood sugars; an LPN stated that blood sugars were not being checked. A blood sugar was then checked and was 581, the physician was notified, and the family requested transfer for evaluation. The next day, Resident R1 was admitted to the ICU with Hyperosmolar Hyperglycemic State, Urosepsis, Hyperglycemia, Hypernatremia, and hypercalcemia. The DON confirmed the facility could not provide evidence that the ordered blood glucose checks were completed as ordered and stated that the order had been transcribed incorrectly into the electronic health record and therefore was not on the MAR.
Failure to Communicate Clinical Information During Hospital Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when residents were transferred to the hospital for five of six residents reviewed: R7, R9, R10, R48, and R54. The clinical records for these residents documented hospital transfers in progress notes, but the records lacked evidence that the required clinical information was sent or otherwise communicated at the time of transfer. R7 had diagnoses including heart failure, atrial fibrillation, and diabetes, and had progress notes indicating transfers to the hospital. R9 had diagnoses including anemia, GERD, and high blood pressure, and had a progress note indicating transfer to the hospital. R10 had diagnoses including encephalopathy, respiratory failure, and sepsis, and had a progress note indicating transfer to the hospital. R48 had diagnoses including quadriplegia, hyperlipidemia, and atrial fibrillation, with progress notes indicating transfers to the hospital. R54 had diagnoses including diabetes, congestive heart failure, and GERD, and had a progress note indicating transfer to the hospital. During interview, the DON confirmed that the records lacked evidence that the necessary clinical information was provided to the receiving health care provider upon transfer.
Failure to Provide Baseline Care Plan and Order Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 25 residents reviewed: R12, R9, and R10. R12 was admitted with diagnoses including malignant neoplasm of the lower lobe of the left bronchus or lung and major depressive disorder, and the clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or representative upon admission. During interview, the NHA and DON confirmed the record lacked evidence of this documentation being provided. R9 was admitted with diagnoses including anemia, GERD, and high blood pressure, and the clinical record lacked evidence that a copy of the baseline care plan, including physician orders for medications, dietary orders, and therapy services, was provided to the resident and/or representative. R10 was admitted with diagnoses including encephalopathy, respiratory failure, and sepsis, and the clinical record also lacked evidence that a copy of the baseline care plan, including physician orders for medications, dietary orders, and therapy services, was provided to the resident and/or representative. During interview, the NHA confirmed there was no evidence that these summaries were provided to R9 and R10 and/or their representatives.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives were offered the opportunity to participate in the development, review, and/or revision of their person-centered care plans for two residents reviewed. Facility policies stated residents have the right to participate in the planning process and that care plans are to be prepared by an interdisciplinary team with resident and/or representative participation to the extent practicable. Resident R14 was admitted with COPD, GERD, and high blood pressure. During interview, R14 did not recall when he/she was last invited to or attended a care plan meeting. The record showed care plan meeting participation on 10/2/25, but there was no evidence that R14 and/or the representative was invited to or attended care plan meetings associated with the 5/8/25, 8/8/25, and 2/8/26 quarterly MDS assessments or the 2/17/26 annual MDS. Resident R60 was admitted with hemiparesis and hemiplegia related to cerebral infarction, diabetes, and high blood pressure. R60 also did not recall when he/she was last invited to or attended a care plan meeting, and the record lacked evidence of invitation to or attendance at care plan meetings for the 6/4/25, 7/16/25, 10/11/25, and 1/11/26 quarterly MDS assessments or the 3/5/26 annual MDS. A Social Worker stated care plan meetings had not been consistently held and were not scheduled in conjunction with the MDS schedule, and confirmed the records lacked evidence that R14 and R60 and/or their representatives were routinely invited to attend.
Missing Care Plan for IV Therapy
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with measurable objectives and timetables for a resident who required IV therapy. Resident R4 was admitted with diagnoses including cerebral infarction, malignant carcinoid tumor of the small intestine, and hypertension. The resident had physician orders for PICC dressing changes and measurement every seven days as needed, and for a daily sodium chloride flush IV solution. Review of the resident's person-centered plan of care showed no evidence that an IV therapy care plan had been developed. During an interview, the DON confirmed that a plan of care for IV therapy had not been developed for the resident and stated that it should have been developed.
Failure to Revise Elopement Care Plan After Resident Elopement
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for Resident R53 to reflect an elopement event. Resident R53 was admitted on 1/16/25 with diagnoses including diabetes, dementia, and hypertension. Facility documents showed that Resident R53 had an elopement on 5/13/25, and the care plan created on 1/17/25 identified the resident as an elopement risk, but it was never revised after the elopement occurred. The Nursing Home Administrator confirmed during interview on 4/9/26 at 1:55 p.m. that the elopement care plan was not reviewed or revised following the event and that care plans should be reviewed and revised as necessary.
Failure to Supervise Resident During Elopement
Penalty
Summary
The facility failed to implement sufficient monitoring and supervision to prevent elopement and failed to adequately carry out search procedures after a resident left the supervised care setting without staff knowledge. The resident involved had diagnoses including diabetes, dementia, and hypertension. An elopement care plan had identified the need for a secure care device at all times, and the resident was last seen about 20 minutes before the event while receiving medication administration. Staff later heard the secure care alarm but did not see the resident inside or near the door, and it was believed the resident left with a small group of visitors. Written statements showed that staff were alerted by a call that a resident might be going up to the road in a wheelchair, and the resident was then found outside in the parking lot being pushed back to the facility. The resident stated he/she was heading to the mall. One LPN reported the resident was outside during dinnertime, while another stated the resident had been encountered about 20 minutes earlier during medication administration and that the charge nurse received a call from someone driving that a resident was outside in the parking lot. The Nursing Home Administrator confirmed the facility failed to properly supervise the resident and failed to respond appropriately to the secure device alarm by completing a head count and thoroughly searching outside the facility.
Soiled oxygen concentrator filters
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred for Resident R60 when the oxygen concentrator filters were found to be heavily soiled. The resident was admitted with diagnoses including hemiparesis, hemiplegia related to cerebral infarction, diabetes, and high blood pressure. The clinical record included a physician’s order for oxygen at 0 to 4 lpm via nasal cannula or mask to maintain oxygen saturation levels at or greater than 90%, and another order to clean the oxygen concentrator filter weekly every Tuesday night shift. During observation, Resident R60 was sitting in a wheelchair with oxygen in place and the concentrator set at 2 lpm via nasal cannula. The concentrator filters on both sides were observed to have a large amount of gray fluffy substance covering the entire filter. An LPN confirmed that the oxygen concentrator filters contained a large amount of gray fluffy substance and should be cleaned. The facility policy stated that external cabinet filters, when present, are to be cleaned weekly by washing them with warm water and allowing them to dry thoroughly before replacing.
Medications Not Dated After Opening
Penalty
Summary
The facility failed to ensure medications were properly dated when opened in one of five medication rooms reviewed and one of five medication carts reviewed. Review of the facility policy on vials and ampules of injectable medications stated that the date opened is recorded by the first person to use each multidose vial, and that multi-dose vials expire 28 days after initial use unless otherwise indicated by the manufacturer. Manufacturer guidance for Tubersol PPD stated that vials entered and in use for 30 days should be discarded, and manufacturer guidance for Lantus insulin stated that opened vials and pre-filled pens should be discarded after 28 days. During observation of the Main Medication Room refrigerator, an opened vial of Tubersol was found without an open date, and staff were unable to determine the expiration date. The DON confirmed the vial lacked an open date. During observation of the D-Wing Medication Cart, an open injector pen of Lantus insulin was found without an open date, and staff were unable to determine the expiration date. An LPN confirmed the Lantus injector pen lacked an open date.
Incomplete and inaccurate clinical record documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents reviewed. Facility policy required the clinical record to provide a complete account of the resident’s care, treatment, response, and progress, and the incident documentation policy required the clinical record to reflect the same information as the incident report with follow-up documentation each shift for 72 hours. For one resident with diagnoses including cerebral infarction, malignant carcinoid tumor of the small intestine, and hypertension, physician orders included dressing changes and measurement of a PICC every seven days and PRN, as well as daily sodium chloride flushes, but the progress notes documented a right chest tunneled CVC instead of the ordered PICC. For another resident with diagnoses including diabetes, dementia, and hypertension, the facility submitted information showing the resident had an elopement, but there was no documentation in the clinical record related to the elopement. During interviews, the Nursing Home Administrator confirmed the record lacked complete documentation related to the elopement, and the DON confirmed the first resident’s clinical record did not have accurate documentation regarding a CVC.
Failure to Ensure RN Assessments for Residents Transferred to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct required assessments for residents who experienced falls, changes in condition, or device dislodgement that led to hospital transfers. Pennsylvania Code Title 49, Chapter 21, specifies that RNs are responsible for assessing human responses, planning, implementing, and evaluating nursing care, and collecting complete and ongoing data to determine nursing care needs. The facility’s own job descriptions state that LPNs administer resident care under RN and/or physician supervision and are to observe, evaluate, and report abnormal findings, while RNs are to observe, assess, and report abnormal findings and significant changes in condition. For seven sampled residents (R10–R16), the clinical records showed events requiring emergency transfer to the hospital, but lacked evidence of RN assessments prior to transfer. One resident with arthropathy, sacroiliitis, Type 2 diabetes, and stroke fell from bed, sustained injury, and was sent to the hospital. Another resident with irregular heartbeat, depression, heart disease, and fibromyalgia fell in the hallway, sustained injury, and was transferred for emergency evaluation. A resident with kidney stones, a displaced kidney drainage tube, UTI, and heart failure required emergency transfer when the kidney drainage tube became displaced. Additional residents with diagnoses including bacterial infection in the blood, heart failure, Type 2 diabetes, irregular heartbeat, high blood pressure, emphysema, COPD, stroke, heart attack, fainting, and heart disease experienced changes in condition that resulted in emergency hospital transfers. Interviews with LPN staff (E1–E5) confirmed that they were expected to complete their own assessments on newly admitted residents, residents with injuries, and residents with changes in condition, and that they were responsible for obtaining provider orders for emergency transfers based on their assessments. These LPNs also reported that there were many times when no RN was available to complete such assessments. Review of the clinical records for the seven residents confirmed the absence of RN assessments before hospital transfer. In an interview, the DON acknowledged that the assessments for these residents were conducted by LPNs without RN oversight or assistance and stated unawareness that an RN was required to perform assessments for residents experiencing a change in condition. The cited regulations included 28 Pa. Code 201.14(a), 201.18(b)(1)(3), 201.18(e)(1), 211.10(d), and 211.12(d)(1)(5).
Failure to Thoroughly Investigate Resident Toe Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an injury of unknown origin sustained by Resident R1. Facility policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property required the investigator to interview the resident, the accused, and all witnesses, obtain statements from each, document evidence of the investigation, analyze the evidence, determine whether the suspicion was substantiated or unsubstantiated, review and revise the resident’s plan of care as appropriate, consider policy or procedure modifications, and complete staff training if indicated. The Nursing Home Administrator later confirmed being unable to locate documentation of interviews or investigation notes related to the resident’s injuries, indicating that the required investigative steps and documentation were not completed as outlined in the policy. Resident R1 had an original admission date of 2/11/25 and a readmission date of 11/11/25, with diagnoses including dependence on renal dialysis, open wounds of the right foot, stage three kidney disease, and gout. Interdepartmental progress notes documented that the resident returned from dialysis in a wheelchair and, approximately 1.5 hours later, staff observed a large amount of blood on the floor and on the resident’s left foot, with a blood clot, blood-soaked sock, and heavy bleeding from abrasions on four toes. The great toe had an open area with tissue missing, the fourth toe was missing the toenail with a bleeding nail bed, and the second and third toes were also bleeding; staff were initially unable to stop the bleeding and applied a pressure dressing. Later that evening, removal of the pressure dressing resulted in renewed bleeding that required cleansing and rewrapping. An email between the NHA and the contracted transport company showed the driver reported being unaware of any injuries to the resident’s toes, but no further investigative documentation was found in the record.
Failure to Use Two Staff for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, weakness, obesity, and vascular dementia was transferred using a mechanical lift by only one nurse aide, despite physician orders and facility education requiring two staff members for all mechanical lift transfers. The staff education materials and clinical records confirmed that two staff are necessary for safe transfers, and this requirement was acknowledged by both the nurse aide and the LPN during interviews. Observation revealed that the nurse aide performed the transfer alone, lowering the resident into bed without assistance. The nurse aide admitted to not following the two-person protocol, and the LPN and Nursing Home Administrator both confirmed that two staff are required for mechanical lift operations. No facility policy was provided for review.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple complaints documented in resident council minutes and resident interviews. Over a three-month period, residents reported persistent issues such as staff being on their cell phones, loud and inappropriate staff behavior in hallways, and delays in call bell responses, particularly during night shifts and weekends. Residents also noted that showers were not completed on designated days, bed sheets were not changed, and meal service was delayed, resulting in cold food and a non-homelike environment. During interviews, several residents described waiting 30 to 60 minutes for assistance after activating their call bells, with some requiring help for restroom use or ambulation that was not provided in a timely manner. Residents observed staff congregating in hallways or lounge areas, talking, watching TV, or using their phones while call lights remained unanswered. These actions and inactions directly contributed to unmet care needs, delays in assistance, and dissatisfaction with the quality of care provided.
Inconsistent Advance Directive Documentation for Life-Sustaining Treatment
Penalty
Summary
The facility failed to ensure that a resident's physician orders, POLST (Pennsylvania Order for Life Sustaining Treatment), and care plan were consistent with each other and accurately reflected the resident's advance directive wishes. Specifically, a review of the clinical record for a resident with diagnoses including kidney failure, GERD, and high blood pressure showed a physician's order and care plan indicating Full Code status, which directs staff to perform CPR in the event of cardiac arrest. However, the resident's POLST, signed by both the resident and physician, indicated DNR (Do Not Attempt Resuscitation), which is a directive to allow natural death and not perform CPR. During an interview, the Director of Nursing confirmed that the physician's orders, POLST, and care plan for this resident were not consistent and acknowledged that all documents should reflect the resident's advance directive wishes. The facility's policy states that a POLST will be honored and should guide care according to the resident or surrogate's wishes, but this was not followed in this case.
Inaccurate MDS Coding for Urinary Continence
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the urinary continence status of a resident. According to the MDS instructions, urinary continence should be coded as 'not rated' if the resident had an indwelling catheter during the entire seven-day look-back period. The clinical record for a resident admitted with kidney failure, GERD, and high blood pressure showed that the resident had an indwelling catheter at the time of admission and throughout the assessment period. Despite this, the resident's admission and Medicare-5 day MDS assessments were incorrectly coded, with urinary continence marked as 'occasionally incontinent' and 'always incontinent' instead of 'not rated.' This coding error was confirmed by the Registered Nurse Assessment Coordinator during an interview, who acknowledged that the MDS assessments did not accurately reflect the resident's continence status as required.
Failure to Obtain Physician's Order for Hospice Services
Penalty
Summary
The facility failed to obtain a physician's order for hospice services for a resident who was readmitted from the hospital with a diagnosis of cerebral infarction, atrial fibrillation, and constipation. Upon readmission, the resident was receiving hospice services from an outside agency, as documented in both hospital records and hospice agency documentation within the clinical record. However, a review of the resident's clinical record revealed that there was no physician's order authorizing hospice services. This absence was confirmed by the Director of Nursing during an interview, who acknowledged that there was no documented evidence of a physician's order for the hospice care being provided since the resident's return.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC line) and an indwelling urinary catheter. According to the facility's policy and CDC guidelines, EBP, including the use of isolation gowns and gloves during high-contact care, should be implemented for residents with indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). However, during observations, there was no signage posted in the resident's room to alert staff or visitors of EBP requirements, and no personal protective equipment (PPE) such as gloves or gowns was available inside or outside the room. The resident involved had a history of kidney failure, GERD, and high blood pressure, and was admitted with both a PICC line and an indwelling catheter. The clinical record did not include a physician's order for EBP. The Director of Nursing confirmed during an interview that the required signage and PPE were not present, acknowledging that these measures should have been in place for residents with indwelling devices. These findings were based on policy review, clinical record review, direct observation, and staff interview.
RN Staffing Deficiency
Penalty
Summary
The facility failed to meet the regulatory requirement of having a minimum of one Registered Nurse (RN) per 250 residents during all shifts. This deficiency was observed over a 14-day period from December 30, 2024, to January 12, 2025. During this time, the facility did not meet the required RN staffing levels for the day shift on 12 out of 14 days, for the evening shift on 13 out of 14 days, and for the overnight shift on 13 out of 14 days. Specific instances included days where no RNs were present despite a resident census that necessitated at least one RN, such as on January 1, 2025, when the census was 102 residents, but no RNs were on duty. The deficiency was confirmed through a review of the facility's nursing staffing documents and a telephone interview with the Nursing Home Administrator. The administrator acknowledged the failure to meet the minimum RN staffing ratios on the specified days and shifts. This lack of adequate RN staffing could potentially impact the quality of care provided to the residents, although the report does not detail any specific adverse outcomes resulting from this deficiency.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure future ratios do not fall below 1 RN per 250 residents on all shifts. The DON or designee will proactively preview daily ratios to ensure adequate staff coverage. The scheduler or designee will review projected staffing levels with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to ensure that any foreseeable issues with regard to adequate ratios to ensure regulation is met. The scheduler or designee will review the working schedules with the Director of Nursing or designee, 3 times a week for 2 weeks, two times a week for 2 weeks, and then monthly for 2 months to determine what changes need to be made to ensure staffing levels are met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. Agency RN usage will be utilized as needed. Scheduler and nursing supervisors have been educated on required staffing ratios. Results of audits will be reviewed at the Quality Assurance committee. 03/05/2025 Date of compliance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that for a period of 21 days, from December 7, 2024, to December 27, 2024, the facility did not have an RN on duty for the required hours. Specific shifts on multiple days were noted where no RN hours were worked, despite the requirement for 8 hours of RN coverage per shift. The deficiency was confirmed during an interview with the Nursing Home administrator on January 2, 2025, who acknowledged the absence of an RN for the required shifts on the specified dates. This lack of RN coverage is a violation of the federal regulation §483.35(b) and the state codes 28 Pa. Code 201.18(e)(1) and 28 Pa. Code 211.12(c), which mandate adequate nursing services and management in long-term care facilities.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. The Director of Nursing or designee will monitor to ensure the facility provides the services of a Registered Nurse (RN) for 8 consecutive hour nursing shifts daily. The scheduler or designee will review projected staffing levels via the daily log to ensure that any foreseeable issues with regard to adequate RN coverage is met. Fairview Manor recruiter will continue to aggressively advertise externally for recruitment of RNs to enhance current staffing levels. Fairview Manor is currently offering a referral bonus to staff for recruiting new employees. Call-in incentives are also being utilized as needed to motivate employees to pick up unscheduled shifts. 1 Full Time day shift Registered Nurse, 1 Full Time night shift Registered Nurse and Director Of Nursing began in General Orientation 1/16/25. Scheduler and nursing supervisors have been educated on required RN/DON staffing requirements. Results of audits will be reviewed at Quality Assurance committee 2/28/25 Date of compliance.
Inaccurate Documentation of Enteral Feeding and Water Flushes
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident identified as R11, who was receiving enteral feeding and water flushes via a gastric tube. The resident's clinical record showed discrepancies in the documentation of the prescribed enteral feeding and water flushes over several months. The physician's orders specified the amounts and frequency of the enteral feeding and water flushes, but the Medication Administration Records (MAR) for January through May 2024 revealed numerous instances of incomplete, inaccurate, or missing documentation. For the enteral feeding, the MARs indicated that the documented intake was often below the ordered amount, with some entries left blank or marked as 'NA' (not applicable). In some cases, the intake was recorded as being above the ordered amount. Similarly, the documentation for the water flushes showed inconsistencies, with entries indicating amounts both above and below the prescribed levels, as well as some entries being left blank or marked incorrectly. During an interview, the Director of Nursing confirmed the presence of incomplete and inaccurate documentation in Resident R11's clinical record concerning the tube feeding formula and water flushes. This deficiency was identified as a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as required by the relevant state codes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manchester Commons Of Presbyterian Seniorcare | 0.3 mi | ★★★★★ | 0 | 0 |
| Lecom At Asbury Ridge Dba Saint Mary's Asbury Ridg | 2.3 mi | ★★★★★ | 9 | 0 |
| Pleasant Ridge Manor East/west | 2.3 mi | ★★★★★ | 0 | 0 |
| Walnut Creek Nursing And Rehab | 5.5 mi | ★★★★★ | 14 | 0 |
| Lecom At Presque Isle, Inc | 6 mi | ★★★★★ | 17 | 0 |
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