The resident's family had expressed concerns about her increasing confusion before September 15, when staff finally ordered a urine test. The lab results came back positive that same day and were immediately posted to the facility's online portal. Staff also received the results by fax.
Nobody looked.
For the next eight days, the resident's condition deteriorated while her test results sat unreviewed in two separate locations that staff checked routinely for other patients. She didn't receive antibiotics until September 23, when the infection control practitioner finally discovered the week-old results.
The delayed treatment violated federal standards for prompt medical care at Fairview Nursing and Rehabilitation Community, according to a November inspection by state health officials.
Infection Control Practitioner I told inspectors she completed a McGeer's criteria assessment on September 23 at 7:57 AM, determining the resident met requirements for antibiotic treatment. McGeer's criteria help facilities decide when residents need antibiotics for suspected infections.
But the practitioner made a critical error on the assessment form. She documented the infection onset as September 19 — four days after the positive lab results were actually available.
"I do not know why I put the 9/19/25 on the McGeer's form," she told inspectors during an October 7 interview. "I do not work weekends."
The practitioner explained her routine: she performs wound rounds with the facility's doctor on Mondays, so she can't check lab results until Tuesdays. She tries to review the laboratory's online portal almost every day from Tuesday through Friday.
"Typically, the facility tries to have labs done on weekends because I am not here to look for results online," she said.
The system broke down completely for this resident. Her urine sample was sent to the lab on September 15, a Monday. The facility received notification through the laboratory's online system the same day that results were positive. Complete culture and sensitivity results were posted online by September 20.
Director of Nursing B acknowledged the failure during an October 8 interview with inspectors. She reviewed the resident's medical chart and the lab's online portal, confirming that results were available much earlier than staff had documented.
"Labs are sent to the fax machine in the pantry at the nurse's station," she explained. "On the weekend of September 20th, me and ICP I were working in the facility on the floor. Both of us should have been looking at the lab website and the fax machine for results, especially with a pending UA."
The director traced exactly when the breakdown occurred. September 15 was a Monday, when the infection control practitioner doesn't check lab results due to wound rounds. That made it the director's responsibility to check for results that day.
"For the week of September 16-19, the ICP should have been looking at both the lab's website portal and the fax machine for the UA results," she said. "It is the expectation of ICP I to look for pending lab results daily and when she does not, then me or the ADON would look for the results even on the weekend."
The director found no evidence supporting the September 19 infection onset date that staff had documented. "The facility had no proof of that because the portal was not reviewed, and the fax results were not reviewed until 9/23/25," she told inspectors.
Meanwhile, the resident's family watched her condition worsen. They had already expressed concerns about increased confusion before the urine test was even ordered. Staff discussed the confusion with therapy staff and tested the resident for dementia, but provided no documentation of increased monitoring for her deteriorating mental state.
"The resident's confusion increased enough to where a UA was ordered," the infection control practitioner explained. "The resident started symptoms of confusion about the same time her UTI was developing."
The facility had multiple safeguards in place that should have prevented the delay. Lab results arrive through both an online portal and fax machine. Multiple staff members have access to check both systems. The director of nursing confirmed the facility "has had no problem with the results coming over on the fax."
On Mondays, either the director or another manager typically reviews lab results online or by fax while the infection control practitioner works with the wound doctor. Weekend managers are also expected to check for pending results.
All of these systems failed simultaneously for eight consecutive days.
The resident met three McGeer's criteria for antibiotic treatment and could have begun treatment as soon as the positive results were available on September 15. Instead, she endured more than a week of worsening symptoms while her test results remained unread in two easily accessible locations.
Federal inspectors determined the delayed treatment caused minimal harm but had potential for actual harm to the resident. The violation affected few residents at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairview Nursing and Rehabilitation Community from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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