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 152 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


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 a complaint, completed on August 21, 2024, it was determined that Fairview Nursing and Rehabilitation Center, was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on review of facility staffing data, it was determined that the facility did not ensure a minimum of one nurse aide (NA) per 10 residents on day, and/or a minimum of 11 residents on evening shift and/or a minimum of one nurse aide (NA) per 15 residents on night shift for the weeks of July 27, 2024, through August 9, 2024.

Findings include:

According to Pennsylvania state regulations, Effective July 1, 2023, require a minimum of one NA per 10 residents on day shift, and a minimum of one NA per 11 residents on evening shift and a minimum of one NA per 15 residents on night shift.

Review of facility's 'nursing staff ratio' for week of July 27, 2024, through August 9, 2024, revealed that facility did not meet ratio's on the following shifts:

July 28, 2024 - day
July 29, 2024 - day
July 30, 2024 - night
July 31, 2024 - day, night
August 1, 2024 - evening
August 2, 2024 - day, night
August 4, 2024 - night
August 5, 2024 - day, night
August 6, 2024 - day, night
August 7, 2024 - day, night
August 8, 2024 - day, night
August 9, 2024 - night

The above findings were discussed with the Director of Nursing on August 21, 2024, at 1:30 p.m.

28 PA Code 211.12 (f.1)(2)

Plan of Correction - To be completed: 09/20/2024

1. The facility reviewed the CNA staffing ratios for 7/28/24 day, 7/29/24 day , 7/30/24 night, 7/31/2024 day and night, 8/1/24 evening, 8/2/24 day and night, 8/4/24 night, and 8/5/24 day and night 8/6/2024 day and night, 8/7/2024 day and night, 8/8/2024 day and night, 8/92024 night. No grievance or residents care were affect on those date due to staffing ratio.
2. Other days were reviewed to see if ratios were met and if care levels were affected.
3. Scheduling coordinator will be educated on CNA ratios for day shift, evening shift, and night shift CNA ratios. Facility will attempt with every reasonable resource to provide a minimum of 1 CNA per 10 residents on day shift, 1 CNA per 11 residents on evening shift, and 1 CNA per 15 residents on night shift.
4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:
Based on review of facility staffing data, it was determined that the facility did not ensure a minimum of one licensed practical nurse (LPN) per 30 residents on evening shift on August 9, 2024.

Findings include:

According to Pennsylvania state regulations, Effective July 1, 2023, a minimum of one LPN per 30 residents on evening shift.

Review of facility's 'nursing staff ratio' for the weeks of July 27, 2024, through August 2, 2024, and August 3, 2024, through August 9, 2024, revealed that facility did not meet LPN ratio as follows:

August 9, 2024 Minimum Req. 3.95; Actual 3.52

The above findings were discussed with facility's Director of Nursing on August 21, 2024, at 1:30 p.m.

28 PA Code 211.12 (F1)(4)

Plan of Correction - To be completed: 09/20/2024

1.The facility reviewed the LPN staffing ratios for 8/9/2024 . No grievance or residents care were affect on that date due to staffing ratio.
2. Other days were reviewed to see if ratios were met and if care levels were affected.
3. Scheduling coordinator will be educated on LPN of 1:25 for day shift, 1:30 residents on evening shift, 1:40 on night shift. Facility will attempt with every reasonable resource to provide care at these ratios.
4. DON/designee will conduct daily audits to verify LPN ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on review of facility staffing sheets, it was determined that the facility failed to provide a minimum of 3.2 hours of direct resident care for each resident in a 24 period for 13 out of 16 sampled days.

Findings include:

Review of facility nursing staffing sheets for the weeks of July 27, 2024 through August 9, 2024, revealed the following days where the staffing hours of direct resident care fell below the required 3.2 hours:

July 27, 2024 - 3.00 hrs
July 28, 2024 - 2.76 hrs
July 29, 2024 - 2.93 hrs
July 30, 2024 - 3.12 hrs
July 31, 2024 - 2.99 hrs
August 2, 2024 - 2.96 hrs
August 3, 2024 - 3.14 hrs
August 4, 2024 - 2.99 hrs
August 5, 2024 - 3.04 hrs
August 6, 2024 - 2.95 hrs
August 7, 2024 - 3.09 hrs
August 8, 2024 - 2.99 hrs
August 9, 2024 - 2.92 hrs

During interview on August 21, 2024 at 1:30 p.m., the Director of Nursing confirmed that the facility failed to meet the nursing hour requirements for these thirteen days.

Plan of Correction - To be completed: 09/20/2024

1. The facility reviewed the total number of general nursing care staffing ratios for 7/27/24, 7/28/24 , 7/30/24, 7/31/2024, 8/2/24, 8/3/24, 8/4/24, 8/5/2024, 8/6/2024, 8/7/2024, 8/8/2024, 8/9/2024. No grievance or residents care were affect on those date due to staffing ratio.
2. Other days were reviewed to see if ratios were met and if care levels were affected.
3. Scheduling coordinator will be educated on general nursing care staffing ratios. Facility will attempt with every reasonable resource to provide care at these ratios.
4. DON/designee will conduct daily audits to verify CNA ratios for all shifts weekly x 4 weeks. Results will be presented to QAPI

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