Fair View Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 4 sampled residents (R1 and R2).R1 made an allegation of abuse against R2 to her daughter that was overheard by an RN (Registered Nurse). The RN did not report the allegation of abuse.CMS's indicates abuse is to be reported within 2 hours, as identified, in part, by 483.12(c)(1) as: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 2 hours if the events that cause the allegation do involve…

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 record review and staff interview the facility did not develop and implement a Comprehensive Resident Centered Care Plan for 1 of 4 residents reviewed (R 2). R2's medical record indicated R1 had occasional sexual inappropriate behaviors. R2's comprehensive care plan does not include a care plan for sexual inappropriate behaviors.Evidenced by:The facility's Multidisciplinary Plan of Care Policy, undated, includes in part the following: D. The comprehensive plan of care is maintained in the electronic medical record (EMR) and is updated to reflect the resident's current status and goals. It will be reviewed at minimum quarterly and per resident need. R2 was admitted to the facility 9/12/24. R2's diagnosis include dementia, history of stroke, osteoarthritis and diabetes. R2's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 8/28/25, includes, in part, the following: R1 usually understands, is usually understood and has severe cognitive impairment. R1's Interdisciplinary Notes includes, in part, the following:9/11/25, 10:07 AM, Care Plan…

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 on interview and record review, the facility did not promptly notify and consult with a physician when a resident experienced a potential change in condition for 1 of 3 resident's (R1) reviewed for physician notification.R1 experienced consistently low blood pressure while taking Metoprolol (a beta blocker that lowers blood pressure) and the facility did not notify R1's physician.The Mayo Clinic, Cleveland Clinic, John Hopkins, University of Wisconsin Hospital, [NAME] Health, and the American Heart Association (AHA) define hypotension (low blood pressure) as being below 90/60 mm Hg (milliliters of mercury).According to the Mayo Clinic, Complications of C. difficile infection include: loss of fluids, called dehydration. Severe diarrhea can lead to a serious loss of fluids and minerals called electrolytes. This makes it hard for the body to work as it should. It can cause blood pressure to drop so low as to be dangerous.Pathway INTERACT's (Intervention to Reduce Acute Care Transfers) vital signs criteria for…

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 interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 1 of 1 resident (R10) reviewed for diabetic foot checks. R10 has no documentation of diabetic foot checks. This is evidenced by: Per ADA (American Diabetes Association), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually. Per AMDA (American Medical Director Association), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at-risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer. It is important to note that the facility did not have a policy for diabetic foot checks. Example 1 R10 has a diagnosis of type 2 diabetes mellitus. R10's medical record was reviewed for documentation of diabetic foot checks. R10's medical record does not include any…

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 on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutritional status (R29). R29 experienced a significant weight loss, and the facility did not assess and notify the physician. Findings include. The facility's policy on weights states: *Each resident will be weighed on admission, day after admission and then weekly, unless stated by the physician. Weights will be taken by the certified nursing assistant (CNA) and reported to the team leader who will record them in the residence record. *If weight changes are identified to be significant, nursing will contact the physician for update and possible recommendations. The facilities policy titled Nutrition Risk Program, states: *The registered dietitian, speech pathologist, registered nurse, or other caregiver should identify the resident at nutritional risk during the initial assessment. * Any member of the healthcare team may alert the nutrition risk team…

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 on interview and record review the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 supplemental residents (R11 and R186) reviewed for antibiotic stewardship. R11 was treated with an antibiotic for an UTI (urinary tract infection) without meeting criteria. R186 was treated with an antibiotic for an UTI and did not meet criteria. Evidenced by: The facility policy, entitled Antimicrobial Stewardship Program, 7/22/24, states, in part: . POLICY: A. (Facility Name) has established and will maintain an antimicrobial stewardship program (AMS). AMS programs promote appropriate antibiotic prescribing practices and play a critical role in reducing antibiotic resistance . C. The Antibiotic Stewardship Team will be responsible for, at a minimum: . b. Ensuring that (Facility Name) follows the Core Elements of Antibiotic Stewardship as recommended by the CDC (Centers for Disease Control) and required by CMS…

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 on interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 5 sampled residents (R14) and 3 of 3 supplemental residents (R10, R15, R18) receiving an anticoagulant medication. The facility did not develop a Care Plan for precautions or monitoring related to use of anticoagulation medication for R10, R15, R14 and R18. Evidenced by: (It is important to note the facility did not have a policy related to the use of anticoagulants.) The facility policy, entitled Multidisciplinary Plan of Care, undated, includes, in part: The multidisciplinary plan of care is developed as soon as possible after the resident is admitted . A basic care plan is developed within 48 hours by the Interdisciplinary Team. A comprehensive care is then developed no later than one week after the completion of the comprehensive assessments (within 21 days after admission) . plan of care includes the following: identified resident needs, identified resident goals which are…

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 on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 2 of 5 residents reviewed for unnecessary medications (R33 & R21). R33 did not have a monthly medication review conducted by a pharmacist. R21 did not have a monthly medication review conducted by a pharmacist. Findings include The facility's Consultant Pharmacist policy states, The pharmacist/contracted pharmacy is responsible for conducting a monthly review of all patients' medication regimens. This review must include a review of the resident's medical chart .The pharmacist must report any irregularities to the attending physician and the facilty's medical director and director of nursing, and these reports must be acted upon. R33 was admitted to the facility on [DATE]. Surveyors requested monthly pharmacy reviews for R33 and the facility was unable to provide any documentation that R33's medications and medical chart had been reviewed by a…

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 record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and pneumococcal immunization for 1 of 5 residents (R25) reviewed for immunizations. R25 did not receive the pneumococcal vaccine. This is evidenced by: The facility's policy titled Pneumovax Vaccine, no date, states in part: A. On admission to LTC (Long Term Care) and with a MD (Medical Doctor) order, pneumovax vaccine will be encouraged for all resident who have not previously received this vaccine .2. Each resident or resident's legal representative receives education regarding the benefits and potential side effects of immunization .5. Refusal of vaccine will be documented in the resident's medical record. 6. Revaccination will be based on current CDC (Centers for Disease Control) . R25's medical record has no evidence or documentation to show that R25 or their representative was provided education,…

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.