Fisher Senior Care and Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to ensure that advance directives were updated in a timely manner and explained in clear language for one resident (Resident #42) of one resident reviewed for code status. Findings Include:Resident #42:On [DATE] at 9:15 AM, a review was conducted of Resident #42's medical record and it revealed she was admitted to the facility on [DATE] with diagnoses that included Anxiety, Intellectual Disabilities and Dementia. Resident #42 her own responsible party. Further review of record yielded the following:Physician Orders:DNR-Do Not Resuscitate - placed on [DATE]Code Status Form:On [DATE] Signed by Resident #42, two physicians and two witnesses that .in the event my heart and breathing stop, no person shall attempt to resuscitate me. Care Plan: .Advance Directives have been discussed & the following has been decided DNR. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that oxygen was administered as ordered for 1 resident (Resident #43) of 1 resident reviewed for respiratory care. Findings Include: Respiratory Care Resident #43:A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #43 was admitted to the facility on [DATE] with diagnoses: Respiratory failure, Primary Pulmonary hypertension, Emphysema, COPD, dependence on supplemental oxygen, and heart failure. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with care. On 4/13/2026 at 1:28 PM, Resident #43 was observed sitting in her room in a wheelchair. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a clinical rationale for administration of duplicate antidepressant therapy for two residents (Resident #4 & Resident #37) and ensure accurate indication for use of an antipsychotic medication for one resident (Resident #43) of seven residents reviewed for unnecessary medications. Findings Include:Resident #4: On 4/14/2026 at approximately 12:00 PM, a review was conducted of Resident #4's medical records and it revealed she readmitted to the facility on [DATE] with diagnoses that included, Metabolic Encephalopathy, Atrial Fibrillation, Major Depressive Disorder and Mood Disorder. Furter review of the record yielded the following:Physician Orders:Mirtazapine Oral Tablet 45 MG (milligrams) for Major Depressive Disorder- started on 9/13/2025Zoloft Oral Tablet 2.5 MG for Major Depressive Disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer insulin per professional standards for one resident (Resident #43) of one resident reviewed for insulin administration, resulting in inaccurate site administration with the likelihood of malabsorption of insulin.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Personal Protective Equipment (PPE) was worn during high contact care for one resident (Resident #4) of one resident reviewed for enteral feeding [a method of delivering liquid nutrients directly into the stomach via a percutaneous gastrostomy tube (PEG)], resulting in the likelihood of transmission of Multi-Drug Resistant Organisms (MDRO).

Inspectors wroteBased 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.

Inspectors wroteBased 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%.

Inspectors wroteThis Citation pertains to Intake Number MI00147136. Based on interview and record review, the facility failed to hold a scheduled 72-hour care conference for one resident (R150) of one reviewed for care conferences, resulting in missing a care conference and lack of information for the family and resident.

Inspectors wroteBased on observation, interview and record review the facility failed to revise care plans for two residents (R19, R39) of a total sample of 17 residents, resulting in missing care plan updates and the potential for unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Resident #13 received vision services and that recommendations were addressed for one resident (Resident #13) of one resident reviewed for vision services, resulting in the lack of follow-up care for vision issues and the potential for vision abnormalities to be untreated or unidentified.

Inspectors wroteBased 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. An IV pole was near the bed and the resident said he was receiving IV antibiotics. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ambient air temperature at a comfortable level, resulting in the potential for uncomfortable living conditions and a non-homelike environment, affecting resident's rooms (#'106, #104, #105, #101 and #203).

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of adequate notice of Medicare Part A benefits of non-coverage for one resident (Resident # 296) of three residents reviewed for notice of non-coverage of Medicare Part A benefits, resulting in the resident's inability to exercise the right to file an appeal in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to complete Minimum Data Set (MDS) assessments timely for two residents (Resident #13, Resident #97) of 19 sampled for MDS assessments, resulting in late annual and admission MDS assessments.

Inspectors wroteBased on interview and record review the facility failed to ensure that transmitted quarterly Minimum Data Set (MDS) assessments were accepted for four residents (Resident #18, Resident #26, Resident #27, Resident #33) of 19 residents sampled for MDS concerns resulting in quarterly MDS assessments being rejected.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the care plan, assess and monitor blood pressure and the heartrate (pulse) for one resident (Resident #31, resulting in unassessed vital signs with the likelihood of blood pressure or pulse changes going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure supervision, call light accessibility and document an unassisted transfer for one resident (Resident #36), resulting in the likelihood of an injury and/or a fall and continued self-transfers going unassessed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Nystatin (oral antifungal medication) timely for one resident (Resident #297), resulting in delayed treatment with the likelihood of continued infection and/or a return of the infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that narcotic storage for the East Medication Cart and narcotic reconciliation was completed legibly for East and [NAME] Medication Carts, resulting in scribbled numbers, unsafe narcotic storage with the likelihood of misappropriation going unnoticed.