Fowler Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of ten sampled residents (Resident 15) were assessed to self-administer and store mediations at bedside when Resident 15 had a bottle of [brand name Carboxymethylcellulose Sodium 1%/Glycerin 0.9% (over the counter eye drop medication used to treat dry eyes)] eye drops stored at bedside for self-administration with no order or Medication Self-Administration Assessment Form (MSA- an assessment form to determine if a resident is clinically appropriate to safely and securely store and self-administer their own medication at bedside). This failure resulted in Resident 15 self-administering and storing medication at bedside without oversight which could lead to duplicate therapy, medication interactions and adverse effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet professional standards of practice for one of ten sampled residents (Resident 41) when Resident 41's physician's order for physical therapy referral was not followed. This failure resulted in Resident 41's physician's order for a physical therapy referral not being implemented, from 3/2/226 to 6/29/26, which could lead to delays in care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the daily nurse staffing information publicly posted accurately reflected actual nursing staffing hours. The facility posted projected nursing staffing hours. This deficient practice had the potential to affect all 42 residents residing in the facility upon entrance. This failure had the potential to prevent residents, resident representatives and visitors from accessing accurate daily nurse staffing information intended to inform the public of the facility's actual nurse staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each residents for one of five sampled residents (Resident 13) when Licensed Vocational Nurse (LVN) 1 did not administer physician ordered apixaban (medication used to prevent blood clots [clumps of blood that can block the blood flow through the body]) 5 milligrams (mg-a unit of measurement that was used to show a very small amount of a medication) twice daily on 7/1/26. LVN 1 was aware of the unavailability of Apixaban and did not notify the pharmacy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and served safely in accordance with professional standards of food service safety for 41 out of 41 residents eating at the facility when six loafs of unopened bread were not labeled of a use by date (is the deadline after which a product may no longer be safe to use) and a opened 2.26 kilogram (kg-a unit of measurement) canister of sour cream was retained past its use by date. This failure placed residents who consumed food from the kitchen at potential risk to be exposed to foodborne illness (food poisoning).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection prevention and control practices were followed for cleaning and disinfecting shared resident care equipment for two of five sampled residents (Resident 13 and 6) when Licensed Vocation Nurse 1 used a blood pressure cuff (a medical equipment used to measure blood pressure) to assess Resident 13, and utilized the same blood pressure cuff for Resident 6 without cleaning or disinfecting the device between residents. This failure had the potential risk for Resident 13 and Resident 6 to be exposed to cross-contamination (the unintended transmission of infectious organisms) through shared resident care equipment.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient supervision to prevent falls for one of six sampled residents (Resident 1), who was assessed as a high fall risk , when Certified Nursing Aide (CNA) 4 left Resident 1 unattended in the restroom while retrieving a diaper and Resident 1 got up from the toilet unassisted, lost his balance and fell. This failure resulted in Resident 1's sustaining a left shoulder fracture. During an interview on 4/2/26 at 2:46 pm with CNA 2, CNA 2 stated CNAs should prepare all necessary supplies before helping residents to the restroom. CNA 2 stated residents must not be left alone in the restroom because they could try to stand up, become unsteady, and fall. CNA 2 stated if additional supplies were needed, CNAs should press the call light button in the restroom and wait for help. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and ice were stored, prepared, and served safely in accordance with professional standards for food service safety for 44 out of 44 residents at the facility when: 1. Honey mustard packets ready for residents' use were expired. 2. Honey mustard packets and frozen sausage pizza toppings were not labeled. 3. A dietary aides personal belonging was observed on the kitchen spice preparation rack. 4. The ice machine water pump (a compartment within the ice machine that carries water) was observed with black spots. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, comfortable and homelike environment for residents, staff and the public when: 1. Five of six resident rooms did not have a properly functioning screen doors and one screen door was missing. 2. Three of sixteen resident doors were not functioning properly. These failures had the potential of violating residents' rights to their privacy and at risk of accidents which could lead to serious health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for five of six sampled residents (Residents' 1, 39, 40, 41, and 97) when: 1. LVN 1 administered medications to Residents' 39, 40, 41 and 97 without closing the privacy curtain or the door. 2. Licensed Vocational Nurse (LVN) 2 checked Resident 1's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. These failures resulted in Residents' 1, 39, 40, 41, and 97 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for 10 of 15 sampled residents (Residents 10, 28, 29, 30, 37, 39, 40, 27, 24, and 14) when: 1. Resident's 10, 29, 30, 37, 39, and 40 did not have care plan for enhanced barrier precautions (EBP-infection control strategy, involving use of gowns and gloves during high-contact resident care). These failures placed Residents' 10, 29, 30, 37, 39, and 40 needs not being met. 2. Resident 28 care plan for Enhanced Barrier Precaution (EBP-a set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]). This failure had the potential for Resident 28's needs being unmet. 3. Resident 27's actives care plan lacked person-centered approach for conversation and socializing. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services provided met professional standards of practice of quality for eight of nine sampled residents (Resident 12, 10, 30, 39, 40, 29, 37 and 28) when: 1. Resident 12 had a physician's order for a low air loss machine (a medical device used primarily to prevent or treat pressure ulcer (bedsores) and was not provided to Resident 12 and was unplugged. This failure resulted for Resident 12 not receiving the necessary care which could lead to development of pressure ulcer. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent. The facility's medication error was 6.9%. 1. Licensed Vocational Nurse (LVN) 1 did not follow medication direction when she administered lactulose solution (medication used to treat constipation) to Resident 40. This failure resulted for Resident 40 not receiving the full therapeutic benefit of the prescribed lactulose solution (medication used to treat constipation) which could lead to constipation or serious health condition. 2. LVN 1 administered metformin (medication used to treat diabetes) medication without food and did not follow the physician's order to administer with food. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infection for 11 out of 11 sampled residents (Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97) when nursing staff did not provide or assist residents in performing hand hygiene before they were served their lunch tray. This failure to provide hand hygiene placed Residents' 8, 9, 23, 24, 26, 33, 35, 39, 41, 44, and 97 at increased risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care that promoted rights of the resident and enhancement of quality of life for one of six sampled residents (Resident 147) when resident 147 was not allowed to smoke. This failure resulted in Resident 147 not being able to smoke since admission which led to decreased sense of pleasure and increased anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment for one of two sampled residents when Resident 12's low air loss machine (designed to distribute patient's body weight over a broad surface area and help skin breakdown) was turned off. This failure had the potential for Resident 12 to develop skin breakdown which could result in pressure ulcer development.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) have the specific competencies, and skill sets necessary to ensure residents who required Enhanced Barrier Precaution (EBP) were properly managed to prevent the risk for infections for seven of seven sampled residents (Residents' 10, 30, 39, 40, 29, 37 and 28) when the IP demonstrated a breakdown in following critical infection control policies and procedures. These failures placed Residents' 10, 30, 39, 40, 29, 37 and 28 at increased risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 27) were provided special eating equipment when Resident 27's lunch was not served on an adaptive equipment scoop plate per her meal ticket. This failure resulted in Resident 27's individualized care needs not met which led to difficulty eating, delayed in finishing her meals and the potential risk for decreased oral intake.

Inspectors wroteBased on observation and interview, during the survey period of 3/4/25 to 3/7/25, the facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 out of 16 rooms (Rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 & 17). This failure had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent elopement for one of three sampled residents (Resident 1) who was a high risk for elopement (when a resident, who is incapable of adequately protecting themselves, departs the facility unsupervised and undetected) when Resident 1 eloped from the facility on 11/6/24. This failure placed Resident 1 ' s safety at risk when Resident 1 was found on the side of the road a mile and a half away from the facility by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 9/2/24. This Failure placed Resident 1's safety at risk when Resident 1 was found on the side of the road half a mile away from the facility by a passing motorist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of one sampled resident (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 6/16/24. This Failure placed Resident 1's safety at risk when Resident 1 was found walking on the side of the road ½ a mile away from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) who was a high risk for elopement when Resident 1 eloped from the facility on 5/15/24 at 7:40 PM and was found by the Sheriff's Department on 5/16/24 at 4 AM in the orchard a mile away from the facility. This failure resulted in Resident 1 leaving the facility without supervision for over eight hours which had the potential to cause injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with the facility's policy and procedure and professional standards for food safety when: 1. [NAME] and gray particles were found in the windowsill (ledge on bottom of window) next to the food preparation sink. 2. [NAME] build up was found on the exterior of the dish washing machine. 3. The ice machine and food preparation sink had no air gaps (a vertical space usually one inch or more between the end of a pipe or faucet and the top of a sink which creates a separation between the water supply and contaminated water). 4. The temperature of the dish washing machine was under the minimum 120° Fahrenheit (F- unit of measurement) requirement. 5. Oven mitts used to handle hot foods were soiled with orange and brown grime and debris. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and safe environment for residents, staff and the public when: 1. The kitchen dry storage floor had areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. 2. The facility floors in the common areas and resident rooms, had black-colored stains, uneven surfaces, cracked linoleum with accumulation of black and brown debris and missing baseboards. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their grievance policy and procedure for five of 15 sampled residents (Residents 18, 27, 28, 37, and 39) when the facility did not ensure Resident 18, 27, 28, 37 and 39 were able to submit grievances anonymously. This failure resulted in Residents 18, 27, 28, 37, and 39 not able to exercise their rights to submit grievances anonymously regarding the facility and their care and could negatively affect their pyschosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate medical record consistent with professional standards and practices for four of 10 sampled residents (Resident 1, 4, 13, and Resident 34) when Resident 1, 4, 13, and 34's Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. These failures resulted in a medical record that did not reflect Resident 1, 4, 13, and 34's treatments for end-of-life care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 27 residents (Resident 28), when Resident 28 was not offered water to rinse her mouth after aerosol oral inhaler (a medication used to prevent difficulty breathing administered by way of inhalation both oral and nasal) administration as ordered by the physician. This failure had the potential for the inhaler medication to accumulate in Resident 28's mouth and placed Resident 28 at risk to developed oral thrush (fungal infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were labeled with resident identifier and expiration date in accordance with the facility's policy and procedure Labeling Medications and Biological's (a substance such as vaccines or drugs derived from a living organism used for treatment) when one Fluticasone propionate salmeterol inhaler (medications used to treat respiratory disease, a mist or spray that the patient breathes in the nose or mouth) and one nasal spray ( liquid medicine spray into the nose) medication was stored in medication cart 1 without a resident identifier label (resident's name and date of birth ) and expiration date. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure to monitor and maintain essential equipment in a safe operating condition for one of six residents, (Resident 4), when Resident 4's oxygen concentrator (a medical device to deliver oxygen) was not routinely monitored and maintained in accordance with facility policy and procedure. This failure had the potential for Resident 4's oxygen concentrator to break down and fail which could result in Resident 4 going without oxygen.

Inspectors wroteBased on observation and interview, during the survey period of 3/12/24 to 3/15/24, the facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms (Rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, & 17). This failure had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to maintain a functioning communication system (call light system-an alerting device used by residents to request assistance from nursing staff) for 17 residents bed (3 C,4 B, 7 D, 9 A,B,D 10 C,D 11 A,B,C 12 A,B,C 14 A,B,C) out of 46 residents bed when the patient call light system warning lights above residents doorway and monitoring panel located in the nurses station to indicate when patients have perceived needs requiring attention were not functioning properly. This failure resulted for residents in the facility not able to call for help and receive immediate assistance from nursing staff which placed residents ' health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant (CNA) 1 met the specific certification requirements when CNA 1 was working in the facility without an active CNA certification. This failure had the potential for Residents not being provided adequate and quality care according to their needs.