Fisher Senior Care and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Feb 23, 2021

  Based on observation, interview and record review, the facility was placed in Immediate Jeopardy due to their failure to institute and operationalize appropriate Infection Control practices in accordance with the Centers for Disease Control and Prevention's (CDC) recommended measures of Cohorting and Isolation of residents diagnosed with [REDACTED]. This included implementation of appropriate interventions, such as Transmission Based Precautions, proper use and storage of Personal Protective Equipment (PPE) and diagnostic testing to prevent the spread of respiratory infections. […]

• Actual harm, isolatedF689Jan 27, 2023

  Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive analysis of falls, accurate documentation, and implementation of meaningful fall prevention interventions for two residents (Resident #2 and Resident #11) of four residents reviewed, resulting in a lack of root cause analysis of falls, inaccurate and incomplete documentation, and a lack of implementation of meaningful interventions following falls. Resident #11 suffered a left shoulder dislocation, fractured the greater tuberosity (head of the humerus bone which rotates in the shoulder joint), and suffered unnecessary pain and the loss of function. […]

• No harm, potential for more than minimal, widespreadF880Feb 22, 2024

  Based on observation, interview and record review, the facility failed to ensure that Infection Prevention and Control standards of practice were followed for 1) Transmission Based Precautions, Hand Hygiene and Central Venous Catheter care for 1 resident (Resident #97), 2) Personal Protective Equipment (PPE) use during medication administration, and 3) Management of soiled and clean linen, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: On 2/20/2024 at 10:46 AM, during a tour of the facility, Resident #97 was observed lying in bed, awake and alert; He readily answered questions. The resident said he was at the facility because he had sores on his left shoulder and bottom. […]

• No harm, potential for more than minimal, patternF584Feb 13, 2025

  Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment for four residents (#'s 28, 37, 100, 101), of seven reviewed for environmental concerns, resulting in personal items not labeled with Resident identification, food not labeled with an open date or refrigerated and the potential for spread of infection and food borne illness. Findings include: Resident #28: On 2/11/25 at 12:16 PM, an interview was conducted with Resident #28 who was sitting up in their wheelchair. The Resident answered questions and engaged in limited conversation. The Resident had a bathroom that was shared with the room next door. There was not a resident in that room at this time. […]

• No harm, potential for more than minimal, patternF759Feb 13, 2025

  Based on observation, interview and record review the facility failed to ensure medications were accurately administered for three residents (R4, R14, R25) of four residents reviewed for medication administration resulting in a medication error rate of 7.69%. Findings include: On 2/12/25 at 7:41am, Licensed Practical Nurse (LPN) 'C' prepared and administered medications for R25. The medications included: Acidophilus, Acetaminophen 500mg, pro-stat, Abilify 2mg, Buspar 5mg, Eliquis 5mg, Glipizide 10mg, Potassium Chloride 10mEq, Senna-S 8.6mg-50mg, Vitamin D 1000mcg, Metoprolol 100mg, Myrbetriq 25mg, Tamsulosin 0.4mg, Cymbalta 30mg, Lasix 40mg and Humalog 2units from an insulin pen. LPN 'C' prepared the insulin pens by dialing in the units to be administered to the resident. […]