Fieser Nursing Center

In the surveyor’s words

From the most serious findings on record at Fieser Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 20, 2024

  Based on interview and record review, the facility failed to ensure residents were free from significant medication error by not administering the resident's seizure medication when an error resulted in the order being deleted from the physician order sheet, for at least three months, for one resident reviewed for hospitalization . This resulted in the resident having a seizure that resulted in hospitalization (Resident #1). The census was 39. Review of the facility's undated Physician's Services policy, showed: -Intent: It is the policy of the facility to provide Physician Services in accordance with State and Federal regulations: -A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs; -Each… […]

• No harm, potential for more than minimal, widespreadF851Sep 30, 2025

  Based on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for three quarters preceding the annual survey. The census was 38. Review of the fiscal years Payroll Based Journal (PBJ) staffing report, showed the facility triggered for failing to submit data for:-Fiscal year quarter 1, 2025 (October 1 to December 31);-Fiscal year quarter 2, 2025 (January 1 to March 31);-Fiscal year quarter 3, 2025 (April 1 through June 30). During an interview on 9/25/25 at 10:18 A.M., the Administrator said she has not been able to log in to the account to submit the PBJ. The account kept saying it was the incorrect password. […]

• No harm, potential for more than minimal, widespreadF636Feb 20, 2024

  Based on interview and record review, the facility failed to complete comprehensive resident assessments on admission and at least annually for six of 12 residents sampled (Residents #101, #104, #102, #51, #52, and #53). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the Admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after… […]

• No harm, potential for more than minimal, widespreadF638Feb 20, 2024

  Based on interview and record review, the facility failed to complete quarterly resident assessments for nine of 12 residents sampled (Residents #55, #101, #104, #102, #51, #54, #151, #53, and #103). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-Admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). 1. Review of Resident #55's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed a quarterly MDS, dated [DATE], in process. 2. […]

• No harm, potential for more than minimal, widespreadF640Feb 20, 2024

  Based on interview and record review, the facility failed to complete and transmit required Minimum Data Sets (MDS, a federally mandated assessment instrument completed by facility staff) as required for 11 of 12 sampled residents (Residents #55, #101, #104, #102, #51, #152, #153, #54, #53, #103, and #151) when the facility failed to ensure staff had the required credentials to submit and transmit MDS data. The facility failed to transmit data since February 2022. This had the potential to affect all residents who reside in the facility. […]