Fellowship Manor

In the surveyor’s words

From the most serious findings on record at Fellowship Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF880Jul 9, 2026

  Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 26 sampled residents. (Resident 6)Findings include: Review of the facility policy titled, Emerging and Other Infectious Diseases, last reviewed June 2026, revealed that a gown and gloves were to be worn with any high contact resident care activity which included wound care. […]

• No harm, potential for more than minimal, isolatedF554Jun 26, 2025

  Based on policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed determine a resident's capability to self administer their medications for one of one sampled residents. (Resident 77) Findings include: Review of facility policy entitled, Self Administration of Medications and Bedside Storage, last reviewed June 2025, revealed that if a resident indicated a desire to self administer medications, a member of the interdisciplinary team was to conduct a skills assessment form with the resident to determine the resident's ability to self-administer medications. Once the form was completed, the assessment was to be kept in the resident's medical record. […]

• No harm, potential for more than minimal, isolatedF605Jun 26, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 78) Findings include: Clinical record review revealed that Resident 78 had diagnoses that included Alzheimer's disease, dementia and anxiety. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication. On June 12, 2025, a physician ordered for staff to administer an anti-anxiety medication, (Ativan), every five hours as needed for agitated behaviors. […]

• No harm, potential for more than minimal, isolatedF689Jun 26, 2025

  Based on clinical record review and review of incident reports it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of nine sampled residents who were at risk for falls. (Resident 78) Findings include: Clinical record review revealed that Resident 78 was admitted on [DATE], and had diagnoses that included Alzheimer's disease, dementia and anxiety. Review of a fall risk evaluation dated February 23, 2025, indicated that he was at a high risk for falls. The Minimum Data Set assessment dated [DATE], indicated that the resident had a memory problem. A review of the care plan revealed that the resident was at risk for falls due to poor safety awareness, impulsivity, a history of falling and confusion. […]

• No harm, potential for more than minimal, isolatedF607Aug 12, 2022

  Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to initiate an employee criminal background check for one of five sampled newly hired employees. (Employee DE 1) Findings include: Review of the facility policy entitled Prevention from Abuse/Neglect/Involuntary Seclusion and Misappropriation of Resident Property, dated July 2022, revealed that if the facility determined an applicant eligible to be hired, a state police background check would be conducted to reduce the risk of hiring an employee likely to abuse residents. Employee DE 1 had been working at the facility since May 28, 2022. […]