Fletcher Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Fletcher Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 12, 2025

  Based on observation, record review, and staff interviews, the facility failed to safely transfer a dependent resident from the bed to the reclining wheelchair using a mechanical lift which resulted in an avoidable injury for 1 of 3 residents reviewed for accidents (Resident #1). On 11/18/25 around 6:30 AM, Nurse Aide #1 independently transferred Resident #1 to the reclining wheelchair and was unhooking the sling straps when the mechanical lift tilted and the sling bar of the mechanical lift hit Resident #1 above the left eyebrow causing a laceration. […]

• Actual harm, isolatedF686Jun 2, 2025

  Based on observations, record review, interviews with the Wound Care Medical Doctor (MD), the Medical Director and staff, the facility failed to obtain treatment orders for pressure ulcers identified on 04/24/25 resulting in a seven day delay of treatment. Additionally, the facility failed to complete accurate head-to-toe skin checks used to identify new or existing pressure ulcers that include the site (location), type of wound, the length, width, depth, and stage. The skin/wound assessment completed on 05/13/25 indicated the resident's skin was intact with no new pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2025

  Based on observations and staff interviews, the facility failed to discard food with signs of spoilage in 1 of 1 walk-in cooler; date and use or discard open food items on or before the best-by date in 1 of 1 walk-in cooler; date open food items in 1 of 1 dry storage room; date and cover an open food item in 1 of 1 walk-in freezer; and failed to implement their infection control policies when Dietary Aide #1 handled ice in the ice machine used to serve residents with her bare hands and when Dietary Aide #2 failed to remove her gloves and perform hand hygiene after handling dirty dishes and before touching other items in the kitchen. These failures had the potential to affect food served to 71 residents. 1. […]

• No harm, potential for more than minimal, patternF641Jun 2, 2025

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #3, Resident #6, Resident #36), pressure ulcer (Resident #86, Resident #74), and Preadmission Screening and Resident Review (PASRR), (Resident #23) for 6 of 8 residents reviewed for resident assessments. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included heart disease. The significant change MDS assessment dated [DATE] revealed Resident #3 was coded as receiving anticoagulant medication. Review of the April 2025 medication administration record (MAR) for Resident #3 revealed there was no physician order for anticoagulant medication and none was administered. […]

• No harm, potential for more than minimal, patternF677Jun 2, 2025

  Based on observations, record review, and resident and staff interviews, the facility failed to provide assistance with oral hygiene and nail care (Resident #86), and showers (Resident #43, #74, and #86) for 3 of 8 dependent residents reviewed for activities of daily living. Findings included: 1 a. Resident #86 was admitted to the facility on [DATE] with diagnoses including obstructive pulmonary disease, pneumonia, and acute respiratory failure. The admission MDS assessment dated [DATE] revealed Resident #86's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #86 had no natural teeth and required setup/cleanup assistance with oral hygiene and partial/moderate assistance with personal hygiene. […]