Pennsylvania Department of Health
FAIRVIEW NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FAIRVIEW NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 139 surveys for this facility. Please select a date to view the survey results.

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FAIRVIEW NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to five Complaints completed on February 29, 2024, it was determined that Fairview Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility did not obtain, clarify and/or follow physican orders related to laboratory studies in a timely manner for one of four records reviewed (Resident R2).

Findings include:

Review of the clinical record for resident R2 revealed that the resident was admitted to the facility for skilled nursing care on March 14, 2013. The admitting diagnoses included but were not limited to; obstructive uropathy (a disorder of the urinary tract that causes a restriction in the flow of urine), chronic kidney disease (a disease of the kidneys that can lead to kidney failure) hypertension (high blood pressure), malignant neoplasm of prostate (cancer of the prostate gland), diabetes (a condition in which the body does not produce enough insulin to regulate blood sugar effectively) and history of urinary tract infections.

Additional review of the clinical record for resident R2 revealed an entry in the progress notes dated January 22, 2024, documenting that the resident left the facility with a family member on that date for an outpatient clinical appointment. Upon return to the facility staff was presented with instructions from consulting physician for a urine culture and a PSA (prostate-specific antigen) test. Further review of the clinical record revealed that the lab studies were not ordered until February 21, 2024.

An interview was conducted with the director of nursing (DON) on February 29, 2024, at 1:00 p.m. The DON confirmed that the lab studies requested by the consulting physician had not been performed in a timely manner.

The facility failed to ensure that physican orders were obtained, followed and/or clarified in a timely manner one of four residents reviewed.

28 Pa Code: 211.5(f) Clinical records.
28 Pa Code: 211.12(d)(1) Nursing services.

Plan of Correction - To be completed: 04/18/2024

1. Resident R2 will have a 30-day look back of consult recommendation to ensure orders are completed.
2. Current consultation recommendations from the past 30 days are in place and completed. New admissions/re-admissions in the last 14 days will have the consult recommendations reviewed by the DON or designee to ensure orders have been reviewed and transcribed per physician order.
3. Nursing staff have been educated in transcribing consult recommendations and ensuring consults are transcribed per MD order. New physician consult recommendations will be reviewed during clinical meetings by DON or designee to ensure transcription.
4. DON/designee will audit new orders weekly x4 weeks to ensure consult recommendations are followed. Results of the audits will be reported to the QAPI Committee for further recommendations as needed.

483.90(g)(1)(2) REQUIREMENT Resident Call System:

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:

Based on observation and interview, it was determined that the facility failed to ensure that the call bell alert system was in working order for one of three nursing units (first floor nursing unit).

Findings include:

During an observation tour of the nursing care unit located on the first floor of the facility on February 29, 2024, at approximately 11:30 a.m. the surveyor initiated the call bell alert system in Resident Room 134 at the bed by the window. The surveyor noted that the call bell alert system did not sound and the visual aid did not light for resident room 134. The surveyor checked with staff at the nursing station and staff confirmed that nurse call bell for room 134 had not been activated.

Interview on February 29, 2024, at approximately 12:30 p.m. with the maintenance director, Employee E3, confirmed that the call bell alert system was not working for the resident in room 134 (window bed).

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 205.67(k) Electric requirements for existing and new construction

28 Pa. Code 207.2(a) Administrator's responsibility

28 Pa. Code 211.12(d)(3) Nursing services

Plan of Correction - To be completed: 04/18/2024

1. Resident room 134 call bell is functioning properly.
2. Residents call bell are in good working condition. A whole house audit will be conducted to ensure there are no malfunctions with the call bells.
3. The Maintenance Director or Designee will in-service staff on ensuring call bells are in good working order. If not in working order the nursing staff will put in a work order in TELS.
4. The Maintenance Director or Designee will complete a whole house audit to ensure the call bells are working properly for X4 weeks. Audits will be reviewed by the QAPI Committee and will determine the need for further audits.

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