Fidelity Health Care

In the surveyor’s words

From the most serious findings on record at Fidelity Health Care, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 7, 2022

  Based on observation, interview and record review, the facility failed to provide wound care services to prevent pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to promote healing of the existing pressure injury for one of two sampled residents (Resident 1) by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) followed Resident 1's care plan and notified Treatment Nurse 1 (TN 1) so TN 1 could notify Physician 1 (MD 1) of the changes in Resident 1's skin condition, on the resident sacral coccyx (tailbone, the bottom of the spine), on 11/1/21, 11/2/21, 11/4/21, and 11/5/21. 2. […]

• No harm, potential for more than minimal, widespreadF851Apr 26, 2024

  Based on interview and record review, the facility failed to ensure Payroll Based Journal (PBJ, a nurse staffing and non-nurse staffing data sets that provide information submitted by nursing homes including rehabilitation services on a quarterly basis) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS, a federal agency within the United States Department of Health and Human Services that administer Medicaid, the Children's Health Insurance Program, and health insurance portability standards) for quarter one of year 2023, from 10/1/2023 to 12/31/23. This failure had the potential to result in CMS not receiving accurate and timely staffing data which could negatively affect the quality of care in the facility. […]

• No harm, potential for more than minimal, patternF684Jul 21, 2026

  Based on interview and record review, the facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) by:Failure to follow the physician's order regarding medication parameters for an antiarrhythmic (used to prevent, treat, or stop abnormal and irregular heart rhythms), alpha-beta blocker (used for combined effect on vessels and heart rate), and loop diuretic (increase urine output) when Resident 1's blood pressure reading was too low.Failure to follow the facility's policies and procedures (P&P) for change of condition and care plan revision to timely monitor and document assessments and interventions for Resident 1.These deficient practices had the potential to negatively affect… […]

• No harm, potential for more than minimal, patternF558Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to ensure call lights were within reach and appropriate to the resident's physical ability for two of two sampled residents (Residents 13 and 56). These failures had the potential for Residents 13 and 56 not to receive necessary care or receive delayed services to meet their needs. Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated the facility initially admitted Resident 13 on 2/7/2023 and readmitted on [DATE] with diagnoses including osteoporosis (weak and brittle bones), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). […]

• No harm, potential for more than minimal, patternF641Jun 5, 2026

  Based on observation, interview, and record review, the facility failed to implement its policy and procedures (P&P) titled, Resident Assessment Instrument, and Minimum Data Set (MDS- a resident assessment tool) for three of three sampled residents (Residents 6, 56, and 83) by failing to ensure the MDS assessment was coded accurately for: a. Resident 6's fall on 4/10/2026.b. Resident 56's psychotic disorder and behavior.c. Resident 83's discharge home from the facility. These failures resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential for Residents 6, 56, and 83 not… […]