Health inspection·May 10, 2024

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 Page 1 of 3 395572 395572 05/10/2024 Fairview Manor 900 Manchester Road Fairview, PA 16415

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. 395572 Page 2 of 3 395572 05/10/2024 Fairview Manor 900 Manchester Road Fairview, PA 16415

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 395572 Page 3 of 3