Farwell Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Farwell Care and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 2, 2023

  Based on interview and record review, it was determined the facility failed to immediately inform the physician and resident representative after a significant change in condition for 1 of 6 Residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall with injuries that resulted in a brain hematoma with a midline shift in which Resident died due to fall. The facility failed to notify Resident #1's Physician and Responsible Party after Resident #1 had a fall resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek. […]

• Immediate jeopardy, isolatedF600Nov 2, 2023

  Based on interviews, observations and record reviews, the facility failed to ensure that residents are free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect. The facility failed to ensure Resident #1 was assessed after a fall on [DATE] resulting in his head hitting the floor and sustaining a laceration to the right eyebrow/cheek . The facility failed to monitor the resident after the fall and after approximately 3.5 hrs. a change in condition was noted resulting in the resident being transferred to the hospital where he expired due to a brain bleed. This failure could place residents at risk of substandard or delay of care, physical harm, or death. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:20 PM. […]

• No harm, potential for more than minimal, patternF610Jul 23, 2026

  Based on interviews and record reviews, the facility failed to thoroughly investigate and document allegations of abuse, neglect, and misappropriation of property for 7 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7).The facility failed to thoroughly investigate and document evidence of five reported allegations of abuse, neglect, and misappropriation of propertyThis failure could result in residents to experience continued abuse or neglect and decreased quality of life.Findings Included:Resident #1Record review of Resident #1's face sheet, dated 07/23/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF583Dec 16, 2025

  Based on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided with the right to have personal privacy during medical treatments, for 4 (Residents #1, #4, #14, and Resident #38) of 15 residents reviewed for privacy. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via peg-tub.-RN D failed to knock or announce herself upon entering Resident #38's room or provide privacy before administering an injectable medication. -RN D failed to knock or announce herself upon entering Resident #14's room or provide privacy before administering an injectable medication. […]

• No harm, potential for more than minimal, patternF726Dec 16, 2025

  Based on observation, interview, and record review, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident for 1 (RN D) of 5 staff reviewed for nursing services. -RN D failed to knock or announce herself upon entering Resident #4's room or provide privacy before administering medication via g-tub.-RN D failed to check placement of g-tube for Resident #4 before administering medication via g-tube. -RN D failed to perform hand hygiene before administering medication to Resident #4 via g-tube. […]