Fowler Residential Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 30, 2024

  The facility reported a census of 16 residents with two residents identified and reviewed for elopement. Based on interview, observation, and record review, the facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, who was identified with an elopement risk and had a known history of elopement, from leaving the facility unsupervised and without staff knowledge. The facility staff last saw R1 on 04/21/24 sometime between 10:00 PM and 11:00 PM. On 04/22/24 at around 03:00 AM, facility staff were unable to locate R1. After searching and notifying Administrative Staff, Law Enforcement, and R1's family, the facility learned R1 was with his sibling in another state, over five hours away. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  The facility reported a census of 16 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to prevent possible food-borne illness among the facility's residents. Findings included: On 02/24/25 at 10:58 AM, during an initial tour of the central kitchen and refrigerator storage areas with Dietary Staff BB, the following areas of concern were identified: One unsealed bag of broccoli, and a container of ranch dressing, in the refrigerator. One sealed bag of onion rings, three bags of hamburger buns, and a bag of hotdog buns without a date or label in the freezer. There was one cutting board with uncleanable surfaces that were discolored along with deep slices that were visible. […]

• No harm, potential for more than minimal, patternF582Feb 26, 2025

  The facility reported a census of 16 residents. The sample included eight residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to two of three residents reviewed, Resident (R) 3 and R11. Findings included: - On 02/26/25 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055 (SNF ABN- the waiver issued by providers when the services might not be covered) and the Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) for three residents. […]

• No harm, potential for more than minimal, patternF919May 10, 2023

  The facility census totaled 14 residents with seven residents residing on hall 100, and one bath house used to bathe those seven residents on that hall. Based on observation, interview, and record review the facility failed to ensure call light accessibility to these seven residents when they received showers in this one bath house. The shower area lacked a cord on the call light located next to the shower making it inaccessible to residents receiving showers and staff providing showers, in case of emergency. Findings include: - Tour of the facility on 05/09/23 at 07:30 AM, revealed a shower room on the hall 100. […]

• No harm, potential for more than minimal, patternF756Aug 30, 2021

  The facility reported a census of 15 residents, with eight residents included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow-up on the recommendations made by the pharmacist for Resident (R)1, R4, R7 and R14 medications. Findings included: - The August 2021 Physician Order Summary revealed R1 with the following diagnoses: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, irritability and anger, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The Annual Minimum Data Set (MDS) dated [DATE] revealed R1 was rarely or never… […]