Fowler Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF692May 24, 2022

  Based on observations, interviews, and record reviews, the facility failed to employ and maintain a Registered Dietitian (RD) to implement and sustain a comprehensive, coordinated, and systematic process for nutrition care to identify residents at nutrition risk and provide nutritional interventions to 10 of 10 sampled Residents (9, 19, 10, 22, 16, 17, 20, 21, 23, 22, and 18) with severe and/or significant weight loss when: 1. Resident 9 experienced a severe unplanned weight loss of 23.4 pounds (lbs. - measurement of weight) (14.7%) from January to May 2022 (five months). Weights were obtained and recorded but weight loss was not consistently communicated to the Physician or RD to determine effective interventions. […]

• Immediate jeopardy, widespreadF725May 24, 2022

  Based on observation, interview and record review, the facility failed to provide sufficient staffing with appropriate competencies and skill sets to meet the needs of the residents when: 1. The facility leadership scheduled one registry (staffing agency) Licensed Vocational Nurse (LVN) to perform medication administration and provide nursing services for 42 of 42 residents from 5/1/22 to 5/10/22 during the morning and evening shifts without completing facility orientation or skills competencies. The facility did not employee a registered nurse (RN) to provide resident care and provide RN oversight of LVN in accordance with the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT). […]

• Immediate jeopardy, patternF686May 24, 2022

  Based on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedure, for three of four sampled residents (Residents 9, 10, and 11) when: 1.Resident 9 was admitted on [DATE] with four stage 2 (a shallow open ulcer/blister), and two unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown] and/or eschar [tan, brown or black] in the wound) and assessments and services to promote pressure ulcer healing were not provided causing Resident 9 to develop two additional pressure and previously… […]

• Actual harm, isolatedF600May 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse for one of two sampled residents (Resident 31) when: 1. The Administrative staff did not evaluate the risk of resident-to-resident abuse prior to rooming Resident 31, who was assessed with known inability to speak and was totally dependent on staff for mobility and assistance, with Resident 2, who had known aggressive behaviors and a history of resident-to-resident physical altercations with other residents and roommates. This failure resulted in Resident 31 being found by staff on 1/21/22, on his bed with bruising, and swelling to left side of face upper cheek, left upper side of the lip and facial expressions of pain that required treatment seven days to heal. […]

• No harm, potential for more than minimal, widespreadF726May 7, 2026

  Based on interview and record review, the facility failed to ensure licensed nurses have the specific competencies necessary to assure residents maintained their highest practicable physical, mental and psychological well-being when Director of Staff Development (DSD) 1 failed to meet the two-year nursing experience qualification. This failure had the potential to result in ineffective staff training, inadequate competency oversight, and negative resident care outcomes. During an interview on 5/7/26 at 11:57 am with DSD 1, DSD 1 stated she had been employed as a Licensed Vocational Nurse as of October 2024 and transitioned to the DSD role on May 1, 2026. […]