4 Reports
Inspection Report — Mar 13, 2024
Annual Inspection
Date: Mar 13, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to provide timely meal service to residents, failure to notify physicians of elevated blood sugar levels as ordered, lack of annual performance reviews and in-service education for nurse aides, improper labeling and dating of nutritional beverages in kitchen refrigerators, failure to submit accurate direct care staffing data, and inadequate ventilation in resident bathrooms and shower rooms.
Deficiencies (6)
F 0550: The facility failed to ensure timely meal service to residents waiting in the dining room, resulting in dignity concerns as some residents waited long periods before being served.
F 0580: The facility failed to notify the physician and document elevated blood sugar levels for Resident #28 as ordered, risking improper insulin management.
F 0730: The facility failed to complete annual performance reviews and provide regular in-service education for four certified nurse aides.
F 0812: The facility failed to label and date opened nutritional beverages in two kitchen nourishment refrigerators, risking contamination.
F 0851: The facility failed to submit accurate direct care staffing data to CMS for the first quarter, resulting in noncompliance with reporting requirements.
F 0923: The facility failed to provide adequate mechanical ventilation in one resident bathroom and two shower rooms, with vents clogged by lint and non-functioning exhaust fans.
Report Facts
Residents waiting for lunch: 13
Resident wait time: 35
Elevated blood sugar levels: 464
Elevated blood sugar levels: 504
Elevated blood sugar levels: 412
Elevated blood sugar levels: 407
Staff performance reviews missing: 4
PBJ data submission failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding meal service delays and kitchen beverage labeling. | |
| Regional Registered Dietitian | Interviewed regarding meal service delays and kitchen beverage labeling. | |
| Licensed Practical Nurse #1 | LPN | Interviewed about failure to notify physician of elevated blood sugar levels. |
| Director of Nursing | Interviewed about failure to notify physician and documentation of elevated blood sugar levels. | |
| Nursing Home Administrator | Interviewed about missing nurse aide performance reviews and PBJ data submission failure. | |
| Maintenance Director | Interviewed about non-functioning exhaust fans and ventilation issues. |
Inspection Report — Dec 18, 2019
Date: Dec 18, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication use, food safety, staff training, and facility conditions at Fowler Health Care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, failure to limit PRN psychotropic medication orders to 14 days, inadequate food service hygiene and freezer temperature control, and incomplete staff training on dementia care and abuse prevention.
Deficiencies (4)
F 0604: The facility failed to ensure residents were free from physical restraints used for convenience and did not re-evaluate or develop a comprehensive care plan for the restraint on Resident #6.
F 0758: The facility failed to limit PRN psychotropic medication orders to 14 days without physician rationale for Resident #33.
F 0812: The facility failed to ensure appropriate hand hygiene by food service staff and maintain freezer temperatures below zero degrees Fahrenheit.
F 0943: The facility failed to ensure all staff had current training on dementia care and abuse prevention, with multiple RNs, LPNs, and CNAs lacking required training.
Report Facts
Residents reviewed: 16
Residents affected: 1
Residents affected: 1
Freezer temperature: 10
Freezer temperature: 14.8
Inspection Report — Dec 20, 2018
Date: Dec 20, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically regarding oxygen therapy for residents.
Findings
The facility failed to provide complete and comprehensive oxygen orders and did not have a baseline care plan addressing oxygen use for Resident #86. Documentation showed inconsistent oxygen liter flow without physician orders or care plans to justify changes.
Deficiencies (1)
F 0695: The facility failed to have complete and comprehensive oxygen orders for Resident #86. The baseline care plan did not include the use of oxygen, and medication and treatment records did not document oxygen therapy.
Report Facts
Residents reviewed for oxygen therapy: 4
Resident oxygen liter flow observations: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Interviewed regarding Resident #86's oxygen use and settings. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about Resident #86's oxygen delivery and titration practices. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about lack of physician order for oxygen therapy. | |
| Director of Nursing (DON) | Interviewed about missing oxygen orders and baseline care plans. |
Report
3 CMS Surveys
CMS Survey — Dec 20, 2018
Dec 20, 2018
CMS Survey — Dec 18, 2019
Dec 18, 2019
CMS Survey — Mar 13, 2024
Mar 13, 2024
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