Fernhill Rehabilitation and Care

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 28, 2025

  Based on interview and record review it was determined the facility failed to timely assist a resident with a transfer for 1 of 3 sampled residents (#3) reviewed for accidents. As a result, Resident 3 was hospitalized and suffered a fractured femur. Findings include: Resident 3 was admitted to the facility in 2024 with diagnoses including diabetes and end stage renal (kidney) disease. Resident 3's 4/5/25 MDS Annual Assessment revealed a BIMS score of 15, indicating no cognitive deficits. Resident 3's care plan, revised 12/2/24, revealed she/he was a fall risk based on her/his medical conditions, lack of safety awareness and poor impulse control. Interventions included to keep the call light within reach and to anticipate and meet Resident 3's needs. […]

• Actual harm, isolatedF684Apr 19, 2021

  Based on interview and record review, it was determined the facility failed to follow the facility bowel protocol and administer physician ordered medication for 1 of 3 sampled residents (#2) reviewed for bowel monitoring and constipation. This resulted in Resident 2 being severely constipated and receiving a fecal disimpaction while at the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Fecal Impaction is an extreme form of constipation in which the contents of the colon become hard and dry, creating a blockage and making it impossible to have a bowel movement. As a result, the contents of the intestines become backed up, leading to potentially serious complications if left untreated. […]

• No harm, potential for more than minimal, widespreadF882Dec 20, 2022

  Based on interview and record review it was determined the facility failed to have a qualified and trained Infection Preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include: On 12/15/22 at 1:59 PM Staff 2 (DNS) identified herself as the Infection Preventionist for the facility, a position she stated she had held for the previous 15 months. Staff 2 stated she had not completed any specialized training in infection prevention and control and was only recently made aware of the training requirement for this position. On 12/20/22 at 9:20 AM Staff 1 (Administrator) confirmed Staff 2 had not completed any specialized training in infection prevention and control.

• No harm, potential for more than minimal, patternF565Aug 8, 2025

  Based on interview and record review it was determined the facility failed to provide resident council members with responses to concerns identified in resident council for 2 of 4 meetings reviewed for resident council. This placed residents at risk for delays in addressing care related concerns and diminished quality of life. Findings include:A 2/2021 Resident Council facility policy states, A Resident Council Response Form will be utilized to track issues and their resolution. […]

• No harm, potential for more than minimal, patternF585Aug 8, 2025

  Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 1 of 3 (#36) sampled residents reviewed for personal property. This placed residents at risk for unaddressed concerns and grievances. Findings include:The facility's 6/1/25 Resident Grievance & Investigation Policy & Procedure directed residents and staff to complete a grievance form with concerns. Grievances were to be conducted and documented on the Resident Grievance Investigation Form with in five working days. […]