Fair Acres Geriatric Center

Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that residents were free from abuse by ensuring staff report timely and implement interventions to prevent abuse. This failure resulted in an Immediate Jeopardy situation.Findings Include:Review of the job description for the Nursing Home Administrator (NHA) revealed that the NHA ensures that the facility operates in compliance with all local, state, and federal regulations. Review of the job description for the Director of Nursing (DON) revealed that the DON is responsible for leading the Nursing Department to provide quality care to the residents based on best practices and regulatory guidelines. The findings in this report identified the facility failed to ensure that allegations of abuse were reported timely and interventions implemented to protect residents from potential abuse. This failure placed residents at risk for serious injury from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and interview with staff, it was determined that the facility failed to inform the resident or resident's representative in advance of treatment risks and benefits, options, and alternatives for one of five residents reviewed (Resident 332).Findings include: Review of Resident 332's clinical record revealed an order on December 12, 2025, for risperidone (antipsychotic medication) 0.25 mg (milligrams) at bedtime for vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), severe, with agitation. An order was received on December 22, 2025, for lorazepam (anti-anxiety medication) 0.5 mg one tablet at bedtime for encounter for palliative care (medical care that relieves pain, symptoms and stress caused by serious illness). An additional order was received on December 30, 2025, for lorazepam 0.5 mg every six hours prn (as needed) for vascular dementia, severe, with agitation. Further review of the clinical record revealed no evidence that the resident or resident's representative was notified in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for one of 35 residents reviewed. (Resident 12).Findings include:Review of Resident 12's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 31, 2025, revealed under section P0100 - Physical Restraints, that the resident was marked as using restraints less than daily.Review of Resident 12's physician's orders revealed that the resident did not have an order for any restraints.Interview with the licensed staff, Employee E6, on February 13, 2026, at 1:40 p.m. confirmed that the resident's MDS assessment was marked incorrectly.483.20 Accuracy of Assessments28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan to address the use of psychotropic medications (any drug that affects behavior, mood, thoughts, or perception, which includes medications for anxiety and antipsychotics) for one of 35 residents reviewed (Resident 332).Findings include: Review of Resident 332's clinical record revealed an order on December 12, 2025, for risperidone (antipsychotic medication) 0.25 mg (milligrams) at bedtime for vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), severe, with agitation. An order was received on December 22, 2025, for lorazepam (anti-anxiety medication) 0.5 mg one tablet at bedtime for encounter for palliative care (medical care that relieves pain, symptoms and stress caused by serious illness). An additional order was received on December 30, 2025, for lorazepam 0.5 mg every six hours prn (as needed) for vascular dementia, severe, with agitation.Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon clinical record review it was determined that the facility failed to follow physician orders regarding fluid restriction for one of thirty-five residents reviewed (Resident 388).Findings include:Review of Resident 388's diagnosis list revealed diagnoses including respiratory failure.Review of Resident 388s physician orders revealed an order for fluid restriction 1800 milliliters (ml) daily - Nursing 7-3 - 300 ml; 3-11 - 180 ml; 11-7 - 120 ml; Dietary - Breakfast - 480 ml; Lunch - 360 ml; Dinner - 380 ml.Further review of Resident 388's clinical record failed to reveal evidence that Resident 388's fluid restriction was being monitored on a daily basis to ensure Resident 388 did not exceed the 1800 ml per day. Interview with the Director of Nursing on February 13, 2026, at 1:00 p.m. confirmed that the facility was not monitoring Resident 388's daily fluid consumption. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of one resident reviewed for nutrition (Resident 348).Findings include:Review of facility policy, Fundamental Nursing Care: - Obtaining Resident Height and Weight, dated March 2023, revealed that A weight gain or loss of 4% within one month requires a follow- up.Weight gain or loss of 4% requires a re-weigh of the resident . Review of Resident 348's clinical record revealed recorded weights of 91.8 pounds on August 29, 2025; 90.8 pounds on September 9, 2025; 84.5 pounds on October 31, 2025 (loss of 6.3pounds or -6.94% in one month). There was no evidence of a re-weigh conducted to address the weight loss.Further review of Resident 348's clinical record failed to reveal recommendations to address the weight loss. Interview with Employee E5 on February 13, 2025, at 10:30 a.m. confirmed that further dietary interventions should have been implemented to address Resident 348's weight loss.28 Pa. Code 211.5(f) Clinical Records28 Pa. Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, facility documentation, resident council minutes, facility policies, and interviews with residents and staff, it was determined that the facility failed to demonstrate evidence that residents are educated on filing grievances and that grievances forms/ boxes were available and accessible for residents on nursing units for five of 5 floors reviewed (Building 8, Floor 3, 4, 5, 6 and 10).Review of facility policy titled Code of Corporate Compliance revealed that Residents are treated in a manner that preserves dignity, autonomy, self-esteem, civil rights and involvement in their own care. Fair Acres Geriatric Center employees receive training about resident rights to clearly understand their role in supporting them. Observation of Building 8, 3rd floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E3, Licensed Practical Nurse, on July 18, 2025 at 10:45 am revealed that there are no grievance forms available and if resident would like to make a complaint they call the phone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon facility policy review, clinical record review, and interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 134). Findings include: Review of facility records revealed a policy titled [NAME] Rx Policy and Procedures Manual, Subject: Medication Regimen Review, dated June 1, 2023, documenting resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the pharmacy's consulting records and reported to the resident's attending physician, the facility's Medical Director and Director of Nursing as appropriate. The physician will accept and document that the irregularity has been reviewed. The attending physician should document his or her rationale in accordance with federal and state regulations. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.