Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on review of clinical records and staff interview, it was determined that the facility failed to maintain
complete and accurate documentation for one of 25 residents reviewed (Resident R11).
Residents Affected - Few
Findings include:
No policy was provided on documentation related to tube feeding.
Resident R11's clinical record revealed an admission date of 10/7/14, with diagnoses that included
gastrostomy (surgical opening into the stomach for nutritional support), dysphagia (difficulty in swallowing
food and liquids, which may interfere with the person's ability to eat and drink) and stroke.
Resident R11's clinical record revealed a physician's order dated 5/20/23, for the enteral feeding of
Fibersource HN (nutritional formula) at 50 milliliters (ml) every hour continuous via gastric tube (a total of
400 ml per shift and 1200 ml total of formula). A physician's order dated 2/12/24, for enteral feeding
revealed to change the Fibersource HN to 55 ml every hour continuous via gastric tube (a total of 440 ml
per shift and 1320 ml total of formula). A physician's order dated 2/12/24, revealed to maintain hydration
flush tube with 100 ml water every four hours (200 ml per shift).
Review of the January 2024 Medication Administration Record (MAR) for Resident R11's enteral feeding
dated 1/1/24, through 1/31/24, revealed that for day shift the documented ml intake was X for 31 of 31 days,
for evening shift the documented ml intake was X for 30 of 31 days and was blank for one of 31 days, and
for the overnight shift the documented ml intake was X for 30 of 31 days.
Review of the February 2024 MAR for Resident R11's enteral feeding dated 2/1/24, through 2/29/24,
revealed that for day shift the documented ml intake was X for four of 29 days and 240 ml below the
ordered amount for two of 29 days, for evening shift the documented intake was X for three of 29 days,
blank for two of 29 days, NA for one of 29 days, and 240 ml below the ordered amount for five of 29 days,
for the overnight shift the documented ml intake was X for two of 29 days, blank for two of 29 days, 240 ml
below the ordered amount for one of 29 days, and 390 ml below the ordered amount for one of 29 days.
Review of the February 2024 MAR for Resident R11's every four hour water flush dated 2/12/24, through
2/29/24, revealed that for day shift the documented ml flush was 240 ml over the ordered amount for one of
17 days, for evening shift the documented ml flush was blank for two of 17 days, was 55/hr for two of 17
days, and was 240 ml over the ordered amount for four of 17 days, for the overnight shift the documented
ml flush was blank for one of 18 days, was 50 ml/hr for one of 18 days, and was
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395572
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395572
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fairview Manor
900 Manchester Road
Fairview, PA 16415
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
240 ml over the ordered amount for five of 18 days.
Level of Harm - Minimal harm
or potential for actual harm
Review of the March 2024 MAR for Resident R11's enteral feeding dated 3/1/24, through 3/31/24, revealed
that for day shift the documented ml intake was 240 ml below the ordered amount for one of 31 days, for
evening shift the documented ml intake was NA for two of 31 days, blank for one of 31 days, zero for one of
31 days, 240 ml below the ordered amount for 18 of 31 days, 340 ml below the ordered amount for four of
31 days, and 476 ml above the ordered amount for one of 31 days, for the overnight shift the documented
ml intake was blank for two of 31 days, and was 240 ml below the ordered amount for six of 31 days.
Residents Affected - Few
Review of the March 2024 MAR for Resident R11's every four hour water flush dated 3/1/24, through
3/31/24, revealed that for day shift the documented ml flush was 240 ml above the ordered amount for one
of 31 days, for evening shift the documented ml flush was blank for one of 31 days, NA for one of 31 days,
was zero for one of 31 days, was 100 ml below the ordered amount for five of 31 days, and was 240 ml
above the ordered amount for three of 31 days, for the overnight shift the documented ml flush was blank
for two of 31 days and was 240 ml above the ordered amount for three of 31 days.
Review of the April 2024 MAR for Resident R11's enteral feeding dated 4/1/24, through 4/30/24, revealed
that for day shift the documented ml intake was 55 ml below the ordered amount for one of 30 days, 110 ml
below the ordered amount for one of 30 days, and 240 ml below the ordered amount for one of 30 days, for
evening shift the documented ml intake was 55 ml below the ordered amount for one of 30 days, 110 ml
below the ordered amount for one of 30 days, 240 ml below the ordered amount for 16 of 30 days, 340 ml
below the ordered amount for five of 30 days, and 786 ml above the ordered amount for 1 of 30 days, for
the overnight shift the documented ml intake was 240 ml below the ordered amount for five of 30 days.
Review of the April 2024 MAR for Resident R11's every four hour water flush dated 4/1/24, through 4/30/24,
revealed for day shift the documented ml flush was 100 ml below the ordered amount for one of 30 days, for
evening shift the documented ml flush was zero for one of 30 days, 100 ml below the ordered amount for
four of 30 days, 130 ml below the ordered amount for one of 30 days, 200 ml above the ordered amount for
one of 30 days, and 240 ml above the ordered amount for three of 30 days, for the overnight shift the
documented ml intake was 240 ml above the ordered amount for five of 30 days.
Review of the May 2024 MAR for Resident R11's enteral feeding dated 5/1/24, through 5/8/24, revealed
that for evening shift the documented ml intake was blank for one of eight days, 220 ml below the ordered
amount for one of eight days, and 240 ml below the ordered amount for four of eight days, for the overnight
shift the documented ml intake was 240 ml below the ordered amount for one of eight days.
Review of the May 2024 MAR for Resident R11's every four hour water flush dated 5/1/24, through 5/8/24,
revealed that for evening shift the documented ml flush was blank for one of eight days, 20 ml below the
ordered amount for one of eight days, 100 ml below the ordered amount for one of eight days, and 100 ml
above the ordered amount for one of eight days, for the overnight shift the documented ml flush was 240 ml
above the ordered amount for three of eight days.
During an interview on 5/9/24, at approximately 3:02 p.m. the Director of Nursing confirmed that Resident
R11's clinical record contained incomplete and inaccurate documentation related to his/her tube feeding
formula and water flushes.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395572
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395572
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Fairview Manor
900 Manchester Road
Fairview, PA 16415
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
28 Pa. Code 201.14(a) Responsibility of licensee
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395572
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the May 10, 2024 survey of FAIRVIEW MANOR?
This was a inspection survey of FAIRVIEW MANOR on May 10, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FAIRVIEW MANOR on May 10, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.