Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fowler Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple prior fractures, muscle weakness, and a documented high fall risk required partial/moderate assistance for toilet transfers. A CNA assisted the resident to the toilet, then left the resident unattended to retrieve a brief instead of using the call light or preparing supplies in advance, despite facility expectations and staff understanding that high-risk residents must be supervised while toileting. During this unsupervised period, the resident attempted to stand, became unsteady, fell against the sink, and sustained a left shoulder fracture, constituting a failure to provide adequate supervision and prevent accidents.
The facility failed to maintain food safety and sanitation standards, affecting all 44 residents. Expired honey mustard packets and unlabeled food items were found, and a dietary aide's cell phone was improperly placed on a spice rack, violating infection control policies. Additionally, the ice machine's water pump had black spots, posing a contamination risk. These deficiencies indicate a failure to ensure a safe and sanitary environment for food preparation and storage.
The facility failed to maintain a safe and homelike environment, with five resident rooms having malfunctioning screen doors and three resident doors not functioning properly. A resident reported issues with his screen and room doors, which were not addressed. Staff, including CNAs and the Maintenance Supervisor, were unaware of the issues, and the Administrator emphasized the importance of maintaining doors for safety. The facility's policies on maintenance were not effectively implemented, leading to these deficiencies.
The facility failed to maintain resident privacy during medication administration and blood sugar checks, as observed with several residents. LVNs administered medications and performed procedures without closing privacy curtains or doors, compromising resident dignity. Facility policies emphasize the importance of privacy, which was not followed in these instances.
The facility failed to develop comprehensive care plans for several residents, including those requiring Enhanced Barrier Precautions and those on anticoagulant medication. This oversight led to unmet needs and potential risks, as care plans are essential for directing staff in meeting residents' needs. The Infection Preventionist and Director of Nursing acknowledged the importance of timely and resident-centered care plans.
A facility failed to maintain professional standards of care for several residents. A resident with a physician's order for a low air loss mattress was found with the device unplugged, risking pressure ulcer development. Additionally, the Infection Preventionist did not obtain necessary physician's orders or perform wound assessments for residents requiring Enhanced Barrier Precautions, increasing the risk of infection transmission.
A facility's medication error rate exceeded the acceptable threshold, with errors involving an LVN administering incorrect dosages and not following administration instructions. One resident received an underdose of lactulose, while another was given metformin without food, contrary to orders. These errors could impact the residents' health, given their medical histories.
The facility failed to maintain an effective infection control program when staff did not provide hand hygiene to residents before meals, increasing the risk of cross-contamination. Interviews with CNAs, an Activities Assistant, and the DON confirmed the oversight, despite the facility's policy requiring hand hygiene. This deficiency was observed during a meal service where residents participated in activities without subsequent hand hygiene.
A resident with no cognitive deficits was not allowed to smoke since admission, despite expressing a desire to do so against medical advice. The facility failed to identify her as a smoker during admission, and no Resident Safe Smoking Assessment was completed. Staff interviews confirmed awareness of her rights, but her choice was not implemented, violating her rights and impacting her quality of life.
A resident with hemiplegia, hemiparesis, dementia, and muscle weakness was found with their low air loss mattress turned off and unplugged, contrary to their care plan. The mattress, essential for preventing skin breakdown, was supposed to be on at all times. Facility staff, including a CNA, LVN, and the DON, acknowledged the oversight, which violated the facility's policy for a safe and homelike environment.
The Infection Preventionist (IP) at a facility failed to manage residents requiring Enhanced Barrier Precaution (EBP) effectively, lacking necessary competencies and skills. The IP did not place physician's orders for residents on EBP, initiate care plans within 24 hours, or document wound assessments, increasing infection risk. The Director of Nursing confirmed the IP's responsibility in identifying EBP needs and ensuring precautions were communicated.
A resident with hemiplegia and other health conditions was not provided with a required scoop plate for her meal, as indicated on her meal ticket. The facility's only scoop plate had broken, and a replacement had not yet arrived. Staff confirmed the importance of the scoop plate for the resident's ability to eat with limited assistance, highlighting a deficiency in meeting her individualized care needs.
The facility did not meet the required minimum square footage per resident in 10 rooms, affecting multiple residents. Despite this, residents had privacy, adequate storage, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect resident health and safety.
A resident with a history of elopement and cognitive impairment managed to leave the facility unsupervised, despite protocols for perimeter checks every 15 minutes. The resident used a kitchen meal cart to climb over the fence and was found a mile and a half away. Staff interviews revealed that the assigned hospitality aide was not performing the required perimeter checks at the time of the incident.
A resident with a history of traumatic brain injury and psychosis eloped from a facility by using a barrel to climb over an 8-foot fence. The resident was found by a motorist half a mile away. The facility's inadequate supervision and security measures, including unalarmed doors and unsupervised outdoor areas, contributed to the incident.
A resident with a traumatic brain injury and mild cognitive impairment eloped from the facility due to inadequate supervision. Despite being identified as an elopement risk, the resident was not on one-to-one monitoring and was found walking on the road by an off-duty CNA. The facility's gate was functioning properly, but the resident's unsupervised departure highlights a lapse in supervision.
A resident with traumatic brain injury and dementia, identified as an elopement risk, left the facility unsupervised and was missing for over eight hours. The resident likely exited with visitors when the gate was unlocked, despite the facility's locked perimeter and policies requiring supervision for at-risk residents.
The facility failed to adhere to food safety and sanitation standards, including unclean windowsills, sediment build-up on the dishwashing machine, lack of air gaps in the food preparation sink and ice machine, inadequate dishwashing temperatures, soiled oven mitts, and improperly labeled food in the resident's refrigerator. These deficiencies were confirmed by the RD, CDM, and POS, indicating non-compliance with the facility's policies.
The facility failed to provide a clean and safe environment, with observations revealing damaged and unsanitary flooring in the kitchen dry storage and common areas. Interviews with staff confirmed the difficulty in cleaning and the potential for contamination and falls. The facility's policies on sanitation and maintaining a safe environment were not upheld.
The facility failed to follow their grievance policy by not ensuring residents could submit grievances anonymously. Residents had to ask staff for grievance forms, which were kept in locked drawers or behind the nurses' station, contradicting the facility's policy. This could deter residents from voicing their concerns and negatively affect their psychosocial well-being.
The facility failed to maintain accurate medical records for four residents, resulting in incomplete Physician Orders for Life-Sustaining Treatment (POLST) forms. Missing information included physician details, preparer information, and additional contact details. Discrepancies were also found in the code status of one resident between the electronic medical record and the paper chart.
A resident was not offered water to rinse her mouth after using an aerosol oral inhaler, contrary to the physician's order. This oversight by the Director of Staff Development increased the risk of oral thrush for the resident, who had moderate cognitive impairment.
The facility failed to label one inhaler and one nasal spray medication with resident identifiers and expiration dates, as observed by the Infection Preventionist. The Director of Nursing confirmed that this oversight placed residents at risk for medication errors and receiving less effective medications.
The facility failed to monitor and maintain a resident's oxygen concentrator, resulting in the equipment being dusty and the filter not being clean. Staff were unsure when the equipment was last cleaned, and the resident expected the concentrator to be properly maintained. The DON acknowledged the need to follow manufacturer instructions but did not provide the maintenance log.
The facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms. Despite this, residents had a reasonable amount of privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms.
The facility failed to maintain a functioning call light system for 17 residents' beds, leading to residents being unable to request assistance from nursing staff. The issue was identified during inspections and interviews, revealing a lack of communication and oversight among staff, and placing residents' health and safety at risk.
A CNA worked for five days without an active certification due to lapses in monitoring by the DON and DSD. The facility did not follow its policy to ensure CNAs' certificates were active, leading to the CNA providing care without proper certification.
Failure to Supervise High-Risk Resident During Toileting Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as a high fall risk during toileting. Certified Nursing Aide (CNA) 4 assisted Resident 1, who had been experiencing loose bowel movements, to the restroom in a wheelchair and noted the resident’s diaper was full of stool. After placing the resident on the toilet, CNA 4 left the resident unattended to retrieve a diaper from the nightstand, instructing the resident not to stand up. When CNA 4 returned, the resident was observed standing, became wobbly, lost balance, and struck his left shoulder on the sink, resulting in a left shoulder fracture before being caught and placed back on the toilet. Resident 1’s records showed multiple relevant conditions, including a history of a broken left arm, broken right shoulder blade, muscle weakness, type 2 diabetes mellitus, anemia, alcohol dependence, conversion disorder with seizures, and a need for assistance with personal care and walking. A Brief Interview for Mental Status (BIMS) score of 3 indicated severe cognitive impairment, and the Minimum Data Set (MDS) nurse stated the resident had difficulty understanding and processing verbal communication, was at high risk for falls, was not good at asking staff for assistance, and liked to self-transfer. The resident’s Fall Risk Evaluation showed a high fall risk score of 11, and an occupational therapy discharge summary documented that the resident required partial/moderate assistance for toilet transfers. Multiple staff interviews and facility documents confirmed that the resident should not have been left alone in the restroom. CNAs 2 and 3, the LVN, the MDS nurse, and the Director of Nursing (DON) all stated that residents, especially those at high risk for falls, should be supervised while toileting and that CNAs are expected to gather supplies beforehand or use the restroom call light to obtain assistance rather than leaving residents unattended. The DON stated that Resident 1 required supervision and that the lack of supervision when CNA 4 left the resident alone in the restroom led to the loss of balance and shoulder injury. The facility’s fall risk policy required an environment free from accident hazards and provision of supervision to prevent avoidable accidents, and professional references cited by the surveyors emphasized remaining with and supervising high-risk patients during toileting.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food and ice were stored, prepared, and served safely in accordance with professional standards for food service safety, affecting all 44 residents. During an observation, expired honey mustard packets were found in the kitchen dry storage room, and the Certified Dietary Manager (CDM) acknowledged that these should have been removed. Additionally, both the honey mustard packets and frozen sausage pizza toppings lacked proper labeling, including receive, open, and use by dates, which the CDM admitted was a responsibility of the kitchen staff to maintain. Further observations revealed a dietary aide's personal cell phone on the kitchen spice preparation rack, which was confirmed by both the CDM and the dietary aide as a violation of the facility's infection control policies. The presence of personal items in the kitchen was identified as a potential risk for cross-contamination and foodborne illness. The Registered Dietician (RD) and the Administrator (ADM) both expressed expectations that personal belongings should not be in the kitchen, aligning with the facility's policies. Additionally, the ice machine's water pump was found to have black spots, which were confirmed by the CDM and Maintenance Supervisor (MS) as a contamination risk. The RD and ADM both expected the ice machine to be clean and free from such substances, as per the facility's infection control policies. The presence of these deficiencies indicates a failure in maintaining a safe and sanitary environment for food preparation and storage, potentially putting residents at risk for foodborne illnesses.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, comfortable, and homelike environment for residents, staff, and the public. During an initial tour, it was observed that five out of six resident rooms had screen doors that were not functioning properly, and one room was missing a screen door entirely. Additionally, three out of sixteen resident doors were not functioning properly, which could potentially violate residents' rights to privacy and increase the risk of accidents. Resident 42, who was admitted with muscle weakness and multiple fractures, reported issues with his screen door and room door, which were not addressed by the facility. Interviews with staff, including Certified Nurse Aides (CNAs) and the Maintenance Supervisor (MS), revealed a lack of awareness and communication regarding the malfunctioning doors. CNA 5 and CNA 6 were not aware of the issues with the screen doors and room doors, and they reported building issues to the MS either in person or through the electronic reporting system, TELS. The MS, upon inspection, confirmed the malfunctioning screen doors and was aware of some door issues due to recent floor installations but had not addressed them yet. The Administrator (ADM) was also unaware of the door issues and emphasized the importance of maintaining doors in good working condition for safety. The facility's policy and procedure on providing a safe and homelike environment, as well as the Maintenance Director's job description, highlighted the need for regular maintenance and prompt reporting of issues. However, these procedures were not effectively implemented, leading to the observed deficiencies.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during medication administration and blood sugar checks. Licensed Vocational Nurses (LVNs) 1 and 2 administered medications to several residents without closing the privacy curtains or doors, compromising the residents' privacy. This occurred for five of six sampled residents, including those with no cognitive deficits and one with moderate cognitive impairment. During observations, LVN 1 administered medications to residents in shared rooms without providing privacy, acknowledging the oversight as a dignity issue. Similarly, LVN 2 checked a resident's blood sugar level without closing the privacy curtain or door, allowing another resident to observe the procedure. Both LVNs admitted they should have ensured privacy during these care activities. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the facility's practice is to provide privacy during such procedures, recognizing it as a matter of resident rights and dignity. The facility's policies on resident rights and medication administration emphasize the importance of maintaining resident privacy, which was not adhered to in these instances.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet needs and potential risks. For six residents, there were no care plans for Enhanced Barrier Precautions (EBP), an infection control strategy involving the use of gowns and gloves during high-contact care. This oversight was identified during a review of the residents' clinical records and confirmed by the Infection Preventionist (IP), who acknowledged that care plans should have been initiated immediately upon placing residents on EBP. The Director of Nursing (DON) and other staff members reiterated that care plans are essential for directing staff in meeting residents' needs. Another resident's care plan for EBP was not initiated in a timely manner, despite the presence of a surgical site that increased the risk of infection. The IP admitted that the care plan was created only after the survey, which was not within the appropriate timeframe. The DON emphasized that care plans should be completed promptly to ensure resident-centered care. Additionally, a resident's activities care plan lacked a person-centered approach, failing to reflect the resident's interests and preferences, which are crucial for their mental, emotional, and physical health. Furthermore, a resident with impaired cognitive function and dementia did not have a timely care plan, potentially increasing the risk of cognitive decline. The facility's policy required care plans to be developed within 14 days, but this was not adhered to. Lastly, a resident on anticoagulant medication did not have a care plan addressing the use of the medication, which is necessary for monitoring potential side effects and ensuring the resident's safety. The DON confirmed that all care plans should reflect residents' needs and active orders to ensure appropriate monitoring and precautions.
Failure to Maintain Professional Standards and Infection Control
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for eight of nine sampled residents. Resident 12, who had a physician's order for a low air loss mattress to prevent pressure ulcers, was found with the mattress unplugged and turned off. This oversight was confirmed by a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), both of whom acknowledged the importance of keeping the mattress operational to prevent skin breakdown. The Director of Nursing (DON) also confirmed that the mattress should have been on at all times, and its failure to operate put Resident 12 at risk of developing pressure ulcers. Additionally, the facility did not adhere to infection control measures for residents requiring Enhanced Barrier Precautions (EBP). Residents 10, 30, 39, 40, 29, 37, and 28 were identified as needing EBP, but the Infection Preventionist (IP) failed to obtain physician's orders, perform wound assessments, or initiate care plans for these residents. The IP admitted to not completing necessary documentation or assessments, which left the status of the residents' wounds unknown. The DON stated that the IP was responsible for identifying residents needing EBP and ensuring appropriate precautions were in place. The facility's failure to implement EBP and maintain necessary medical equipment as per physician's orders highlights significant lapses in adhering to professional standards of care. The lack of documentation and oversight in infection control measures increased the risk of infection transmission among residents, while the failure to maintain the low air loss mattress compromised the care of Resident 12, potentially leading to the development of pressure ulcers.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 6.9%. This deficiency was identified through observations, interviews, and record reviews. One incident involved an LVN administering an incorrect dosage of lactulose solution to a resident, providing only 20 ml instead of the prescribed 30 ml. This underdosing could prevent the resident from receiving the full therapeutic benefit of the medication, which is used to treat constipation. The resident had a medical history that included alcoholic cirrhosis of the liver and duodenal ulcer, conditions that could be exacerbated by improper medication administration. Another incident involved the same LVN administering metformin to a different resident without food, contrary to the physician's order to give the medication with meals. This oversight could lead to gastrointestinal distress and affect the medication's absorption, potentially compromising blood sugar control. The resident had a medical history of diabetes, anemia, and muscle weakness. Interviews with other staff members, including the Director of Nursing, emphasized the importance of adhering to medication orders to ensure effective treatment and prevent adverse effects.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as observed during a meal service in the dining room. Staff did not provide or assist residents with hand hygiene before serving lunch trays to 11 sampled residents. This oversight was noted during an observation on March 4, 2025, at 11:50 a.m., where residents were assisted by staff for lunch, but no hand hygiene was offered or provided. The lack of hand hygiene placed these residents at increased risk for cross-contamination. Interviews with staff members, including CNAs, an Activities Assistant, an LVN, and the Director of Nursing, revealed a consistent acknowledgment of the failure to provide hand hygiene. CNA 8 and CNA 9 admitted that they did not offer hand hygiene to residents before meals, despite understanding its importance in preventing gastrointestinal issues. The Activities Assistant also confirmed that residents participated in activities involving contact with various surfaces before lunch without subsequent hand hygiene. The Director of Nursing expressed an expectation for staff to ensure residents' hands were cleaned before meals. The facility's policy and procedure on infection prevention and control, dated 2024, mandates that all staff follow established hand hygiene procedures. However, this policy was not adhered to during the observed meal service. The Dietary Aide's job description also emphasizes the importance of following safety and hygiene measures to protect residents, which was not followed in this instance. The failure to provide hand hygiene before meals was a clear deviation from the facility's established protocols, leading to the identified deficiency.
Resident's Right to Smoke Not Upheld
Penalty
Summary
The facility failed to uphold the rights of a resident, identified as Resident 147, by not allowing her to smoke since her admission. Resident 147, who was admitted with multiple diagnoses including psychosis, major depressive disorder, schizoaffective disorder, opioid dependence, and insomnia, expressed a desire to smoke despite medical advice against it. Her Minimum Data Set assessment indicated no cognitive deficits, suggesting she was capable of making informed decisions about her care. Despite being educated on the risks of smoking before her throat healed, Resident 147 consistently expressed her wish to smoke, which was not honored by the facility. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed that they were aware of Resident 147's desire to smoke and her right to do so against medical advice. However, due to an oversight during the admission process, Resident 147 was not identified as a smoker, and no Resident Safe Smoking Assessment was completed. This lack of assessment and documentation led to the failure to include her in the facility's Resident Smoking Binder, which tracks residents who smoke and their supervision needs. The facility's policies and procedures, as well as job descriptions for staff, emphasize the importance of respecting and promoting residents' rights, including the right to make personal choices. Despite this, the facility did not implement Resident 147's choice to smoke, resulting in a violation of her rights and a negative impact on her quality of life, as she experienced increased anxiety and a decreased sense of pleasure during her stay.
Failure to Maintain Resident's Low Air Loss Mattress
Penalty
Summary
The facility failed to provide a safe and homelike environment for Resident 12, as observed during a survey. Resident 12, who was readmitted to the facility with diagnoses including hemiplegia, hemiparesis, dementia, and muscle weakness, was found lying in bed with a low air loss mattress that was turned off and unplugged. This mattress is crucial for distributing the resident's body weight to prevent skin breakdown and pressure ulcers. The resident's Minimum Data Set assessment indicated a moderate cognitive deficit, which may have contributed to their inability to communicate effectively about their discomfort or needs. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing, revealed that the low air loss mattress was supposed to be on at all times as per the resident's care plan to prevent skin breakdown. The CNA and LVN both acknowledged the oversight, and the DON confirmed that it was the nursing staff's responsibility to ensure the mattress was functioning properly. The facility's policy on providing a safe and homelike environment was not adhered to, as the unplugged mattress posed a risk to the resident's safety and well-being.
Inadequate Infection Control by Infection Preventionist
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) possessed the necessary competencies and skills to manage residents requiring Enhanced Barrier Precaution (EBP) effectively. This deficiency was identified during interviews and record reviews, revealing that the IP did not follow critical infection control policies and procedures. Specifically, the IP did not place physician's orders for seven residents on EBP, as required by facility policy. Additionally, the IP failed to initiate EBP care plans within 24 hours and did not complete assessments or documentation for the residents' wounds, leaving the status of the wounds unknown. The residents involved in this deficiency included individuals with various medical conditions such as diabetes, open wounds, cellulitis, and muscle weakness. Despite some residents having no cognitive deficits, the lack of proper infection control measures placed them at increased risk for infection. The Director of Nursing (DON) confirmed that the IP was responsible for identifying residents needing EBP and ensuring the necessary precautions were communicated and implemented. The DON expected the IP to obtain physician orders promptly and fulfill her role in infection prevention and control.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a resident with the necessary adaptive eating equipment, specifically a scoop plate, as indicated on her meal ticket. This deficiency was observed when the resident's lunch was served on a regular plate instead of the required scoop plate. The Certified Dietary Manager (CDM) confirmed that the resident's meal ticket specified the need for a scoop plate, which was determined by occupational therapy and listed on the meal ticket. However, the facility did not have a scoop plate available because the only one they had broke the previous day, and a replacement had been ordered but had not yet arrived. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, type 2 diabetes mellitus with ophthalmic complications, muscle weakness, and chronic kidney disease, was observed eating with her fingers due to the absence of the scoop plate. The resident expressed that she typically used a special plate that helped her eat, and without it, she experienced difficulty and delays in finishing her meals. Interviews with various staff members, including the Director of Staff Development, Registered Dietician, Licensed Vocational Nurse, and Certified Nursing Assistant, confirmed that the scoop plate was essential for the resident to eat with limited assistance and that its absence posed a risk for decreased oral intake. The facility's job descriptions and policies indicated that dietary staff were responsible for ensuring meals were plated according to meal tickets, including the provision of adaptive equipment. The Director of Nursing and Administrator both stated that they expected meal ticket orders to be followed accurately. The deficiency was attributed to the lack of a scoop plate, which was a critical adaptive device for the resident's eating needs, and the failure of the facility to ensure its availability and use as required by the resident's care plan.
Deficiency in Room Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain the required minimum square footage per resident in 10 out of 16 rooms during the survey period. Specifically, rooms 1, 2, 5, 6, 11, 12, 14, 15, 16, and 17 did not meet the required 80 square feet per resident for multiple occupancy rooms. Despite this deficiency, the report notes that residents had privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver for these rooms did not adversely affect the health and safety of the residents residing in them.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was at high risk for elopement. The resident, who had a history of traumatic brain injury, alcohol dependence, seizures, and moderate cognitive impairment, managed to leave the facility unsupervised and was found a mile and a half away. The resident had previously eloped by using objects to climb over the facility's fence, and despite measures such as perimeter checks every 15 minutes, the resident was able to elope again. On the day of the incident, a hospitality aide was assigned to monitor the facility's perimeter but was inside the building instead of performing the required checks. A kitchen meal cart was found next to the fence, which the resident used to climb over and leave the premises. The staff was alerted to the resident's absence when the hospitality aide noticed the cart and initiated a head count, leading to the discovery of the resident's elopement. Interviews with staff revealed that the hospitality aide was expected to remain outside and conduct perimeter checks every 15 minutes, but this protocol was not followed. The facility's policy required adequate supervision and removal of potential elopement aids, but these measures were not effectively implemented, resulting in the resident's unsupervised departure.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for elopement, resulting in the resident eloping from the facility. The resident, who had a history of traumatic brain injury, psychosis, and other conditions, was found by a passing motorist half a mile away from the facility. The resident had used a barrel placed on top of a wheelchair to climb over an 8-foot fence surrounding the facility. The incident occurred when the resident was last seen heading towards their room, and shortly after, a call was received from a motorist who found the resident on the side of the road. The facility's maintenance supervisor and other staff confirmed that the resident had used the barrel to climb over the fence, which should not have been left near the fence. The facility's policy on elopement and wandering residents was not effectively implemented, as the resident was able to leave the premises without adequate supervision. The facility had four doors leading outside, with only two equipped with alarms, and the fenced area was used by residents to get fresh air without supervision. The facility's administrator acknowledged that the facility was known for admitting residents at risk of elopement, yet the supervision and security measures in place were insufficient to prevent this incident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for elopement, resulting in the resident leaving the facility unsupervised. The resident, a male with a traumatic brain injury and mild cognitive impairment, was found walking on the side of the road half a mile away from the facility. The resident's care plan identified him as an elopement risk due to impaired safety awareness and wandering behavior, yet he was not on one-to-one monitoring at the time of the incident. On the day of the elopement, the resident was last seen by staff around 10:30 a.m. during a smoke break. The facility was unaware of the resident's absence until a CNA, who was off duty, noticed him walking on the road and returned him to the facility. Interviews with staff revealed that the resident had previously attempted to pick the gate lock and often sat near the gate, trying to leave when staff entered or exited. Despite these behaviors, the resident was not under constant supervision. The facility's front gate, the only entry and exit point, was observed to be functioning properly, with no signs of tampering. Staff members who interacted with the gate on the day of the incident confirmed that it closed securely each time. However, the exact moment and method by which the resident eloped remain unclear. The facility's policy on elopement and wandering residents emphasizes the need for adequate supervision, which was not provided in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was at high risk for elopement. This resident, diagnosed with traumatic brain injury and dementia, was able to leave the facility unsupervised. The resident was missing for over eight hours before being found by the Sheriff's Department in an orchard a mile away from the facility. The incident occurred when the resident likely exited the facility with a group of visitors, unnoticed by the staff. The resident's care plan, which identified them as an elopement risk due to impaired safety awareness and cognitive function, indicated that the resident should not leave the facility unattended. Despite this, the resident was able to leave the premises, suggesting a lapse in the supervision and security measures that were supposed to be in place. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and the use of door locks and alarms to prevent such incidents. Observations of the facility revealed a 7-foot-tall metal fence surrounding the premises, with locked gates that required a key for access. The Director of Nursing confirmed that the facility was locked, and only staff had keys to the gates. However, the resident was able to leave the facility, likely slipping out with visitors when the gate was unlocked for them. This indicates a failure in the facility's procedures to ensure that residents at risk of elopement are adequately supervised and prevented from leaving the facility without authorization.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with its policy and professional standards for food safety. Brown and gray particles were found on a windowsill above the food preparation sink, which had the potential to contaminate food. The Registered Dietitian (RD) and Certified Dietary Manager (CDM) confirmed that the windowsill should have been cleaned daily, and the facility's policy required weekly sanitation inspections. Additionally, white sediment build-up was found on the exterior of the dishwashing machine, which could harbor bacteria and contaminate dishes. The RD and CDM acknowledged that the build-up should have been cleaned and that the facility's policy was not followed in this regard. The facility also failed to maintain proper air gaps in the food preparation sink and ice machine, which could lead to sewage water backflow and contamination. The Plant Operations Supervisor (POS) and RD confirmed the absence of air gaps and the potential for contamination. The facility's policy required weekly inspections to ensure compliance with sanitation and food service regulations, which were not adhered to in this case. Furthermore, the dishwashing machine's temperature was observed to be below the minimum requirement of 120°F, which could result in improperly sanitized dishes. The RD and CDM stated that the temperature should be between 120°F and 140°F, and the facility's policy required frequent temperature checks and immediate correction of inadequate temperatures. Additional deficiencies included the use of soiled oven mitts by dietary staff and improperly labeled food in the resident's refrigerator. The RD and CDM confirmed that oven mitts should be cleaned daily to prevent food contamination, and the facility's policy required weekly sanitation inspections. Food stored in the resident's refrigerator was not labeled with the resident's name and use-by date, which could lead to giving the food to the wrong resident and compromised food quality. The RD, CDM, and a Certified Nursing Assistant (CNA) confirmed that the food should be labeled according to the facility's policy to ensure proper identification and quality.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean and safe environment for residents, staff, and the public. Observations revealed that the kitchen dry storage floor had multiple areas of brown stains, missing and cracked linoleum, exposing the cement underneath with an accumulation of dark gray debris. Interviews with the Certified Dietary Manager, Plant Operations Supervisor, and Registered Dietitian confirmed that the damaged floor was difficult to clean, unsanitary, and could potentially contaminate the food stored in the dry food storage room. The facility's policy and procedure on sanitation inspection and the FDA Food Code were reviewed, indicating that all food service areas should be kept clean, sanitary, and easily cleanable, which the facility failed to comply with. Additionally, the facility floors in common areas and resident rooms had black-colored stains, uneven surfaces, cracked linoleum with an accumulation of black and brown debris, and missing baseboards. Interviews with the Plant Operations Supervisor, Infection Preventionist, and Administrator confirmed awareness of the damaged flooring and the need for repairs to ensure a safe and homelike environment. The Infection Preventionist highlighted that the uneven floor surfaces could cause falls and that clean floors are essential to prevent the spread of germs. The facility's policy on maintaining a safe, clean, comfortable, and homelike environment was reviewed, indicating that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior, which the facility failed to uphold.
Failure to Ensure Anonymous Grievance Submission
Penalty
Summary
The facility failed to follow their grievance policy and procedure for five of 15 sampled residents when it did not ensure they were able to submit grievances anonymously. During a resident council meeting, the residents stated they did not know how to file anonymous grievances. One resident specifically mentioned not knowing how to submit grievances anonymously. Interviews with the Social Services Director (SSD) and the Activities Director (AD) revealed that grievance forms were kept in locations that required residents to ask staff members for access, thus preventing an anonymous submission process. The SSD acknowledged that the current process did not allow for truly anonymous grievance filing and recognized the importance of such a process to prevent fear of reprisal from residents against the facility or staff members. The facility's policy and procedure titled 'Resident and Family Grievances,' dated October 2023, indicated that grievances could be filed anonymously. However, the practice of keeping grievance forms in locked drawers or behind the nurses' station contradicted this policy. The SSD admitted that the facility did not ensure residents could file grievances anonymously without staff intervention, which could deter residents from voicing their concerns. This failure could negatively affect the psychosocial well-being of the residents involved.
Incomplete POLST Forms for Four Residents
Penalty
Summary
The facility failed to maintain accurate medical records consistent with professional standards and practices for four residents. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 1, 4, 13, and 34 were incomplete. The deficiencies included missing physician information such as name, address, phone number, license number, and signature, as well as missing preparer information and additional contact details. These omissions were identified during interviews and record reviews with the Medical Records Director (MRD) and the Director of Nursing (DON). The MRD acknowledged that the POLST forms should have been completed to ensure that the residents' end-of-life care preferences were followed, especially in the event of a transfer to another facility. Resident 1's POLST, dated 8/2/23, was missing all physician information, the preparer's details, and additional contact information. Resident 1 had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 99. Resident 4's electronic medical record (EMR) indicated a Full Code status, while the paper chart indicated a Do Not Resuscitate (DNR) status, leading to a discrepancy in the resident's code status. Resident 4 had a BIMS score of 12, indicating moderate cognitive impairment. Resident 13's POLST, dated 3/13/24, was missing the physician's phone number, and Resident 13 had severe cognitive impairment with a BIMS score of 99. Resident 34's POLST, dated 1/11/24, was missing the physician's printed name and phone number, as well as the preparer's information and additional contact details. Resident 34 was cognitively intact with a BIMS score of 15. The facility's policy and procedure for documentation in medical records, dated 10/22, required that all assessments, observations, and services provided be accurately documented in the resident's medical record. The Medical Records Clerk's job description also emphasized the importance of ensuring that resident records are properly completed before filing. Despite these policies, the facility failed to maintain complete and accurate POLST forms for the four residents, resulting in medical records that did not fully reflect the residents' end-of-life care preferences and treatments.
Failure to Follow Physician's Order for Inhaler Administration
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for Resident 28 when the Director of Staff Development (DSD) did not offer water to rinse her mouth after administering an aerosol oral inhaler. This was observed during a visit, and it was noted that the physician's order specifically required the resident to rinse her mouth with water and spit it back into a cup after using the inhaler. The failure to follow this order had the potential to cause the medication to accumulate in Resident 28's mouth, increasing the risk of developing oral thrush, a fungal infection. Resident 28's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12, suggesting moderate cognitive impairment. During an interview, the Director of Nursing (DON) confirmed that the expectation was for the DSD to follow the physician's order to prevent oral thrush. The facility's policy on the provision of physician-ordered services emphasized the importance of adhering to professional standards of quality. Additionally, the Federal Drug Administration's prescribing information for the inhaler medication highlighted the necessity of rinsing the mouth to prevent localized infections such as thrush.
Failure to Label Medications with Resident Identifiers and Expiration Dates
Penalty
Summary
The facility failed to ensure that drugs were labeled with resident identifiers and expiration dates in accordance with the facility's policy and procedure. Specifically, one Fluticasone propionate salmeterol inhaler and one nasal spray medication were found in medication cart 1 without a resident identifier label and expiration date. This was observed during a concurrent observation and interview with the Infection Preventionist (IP) in front of the nurse's station. The IP confirmed that the medications should have been labeled to prevent giving the medication to the wrong resident and to ensure medication efficacy. The Director of Nursing (DON) stated that her expectation was for the inhaler and nasal spray medication to be labeled with resident identifiers and expiration dates. The DON acknowledged that the lack of proper labeling placed residents at risk for medication errors and receiving less effective medications. A review of the facility's policy and procedure titled 'Labeling of Medications and Biologicals' indicated that all medications should be labeled in accordance with federal and state requirements and current accepted pharmaceutical principles, including the resident's name, prescribing physician's name, medication name, prescribed dose, strength, quantity, expiration date, and route of administration.
Failure to Maintain Oxygen Concentrator
Penalty
Summary
The facility failed to follow policy and procedure to monitor and maintain essential equipment in a safe operating condition for one resident when the resident's oxygen concentrator was not routinely monitored and maintained. During an observation and interview, it was noted that the oxygen concentrator had gray particles and dust on the surface, and the filter was not clean. The Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) both acknowledged that the equipment was dusty and should be cleaned, but they were unsure when maintenance last cleaned the filter. The resident expressed an expectation that the oxygen concentrator should be clean and properly maintained. The Director of Nursing (DON) stated that the facility was expected to follow manufacturer instructions for the use and maintenance of the oxygen concentrator but failed to provide the maintenance log and instructions for use (IFUs). The facility's policy and procedure indicated that the oxygen concentrator should be cleaned and maintained according to the manufacturer's recommendations, which include routine maintenance and regular checking of the filters. The facility's Resident-Care Equipment Policy also emphasized the importance of cleaning and disinfecting reusable resident-care equipment to prevent the transmission of pathogens.
Failure to Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms. Specifically, rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, and 17 did not meet the required square footage requirements. Despite this, residents had a reasonable amount of privacy, adequate closets and storage space, bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system for 17 residents' beds, which are essential for residents to request assistance from nursing staff. During an observation, interview, and record review, it was found that the warning lights above residents' doorways and the monitoring panel located in the nurse's station were not functioning properly. This issue was identified during a series of interviews and inspections conducted by the Maintenance Supervisor (MS), Administrator (ADM), and Director of Nursing (DON). The MS admitted to conducting daily inspections but failed to check the monitoring panel at the nurse's station, leading to the malfunction going unnoticed. Both the ADM and DON confirmed the malfunction during their inspection, and several staff members, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), were unaware of the issue, indicating a lack of communication and oversight. The deficiency was further highlighted during interviews with the Plant Supervisor Environment (PSE) and the ADM, who acknowledged the importance of a functioning call light system for resident safety. The facility's policy and procedure on call lights, dated November 2022, emphasized the need for a properly functioning call light system to ensure residents can call for assistance. However, the MS did not perform a detailed inspection, and the ADM was unaware of the frequency of these checks, leading to the malfunction affecting 17 residents' beds. This failure placed residents' health and safety at risk, as they were unable to call for help and receive immediate assistance from nursing staff.
CNA Worked Without Active Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) met the specific certification requirements, resulting in CNA 1 working without an active CNA certification. The Director of Nursing (DON) and the Director of Staff Development (DSD) were both unaware that CNA 1's certification had expired, leading to CNA 1 being scheduled and working for five days without an active certificate. The DON acknowledged that it was her responsibility to monitor the status of licenses and certificates for all employees and admitted that the facility did not follow its policy and procedure for ensuring CNAs' certificates were active. During interviews, both the DON and the DSD admitted to lapses in their responsibilities. The DSD stated she was responsible for monitoring certifications and helping CNAs with renewals but was unaware of the expiration. The Administrator also confirmed that CNA 1 should not have been scheduled to work without an active certificate and acknowledged her oversight responsibility. The facility's policy and job descriptions clearly outlined the need for active certification, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 332 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fowler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyards At Fowler | 1.7 mi | ★★★★★ | 25 | 0 |
| Rolling Hills Care Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Bethel Lutheran Home | 5.2 mi | ★★★★★ | 19 | 0 |
| Grace Healthcare Center | 6.1 mi | ★★★★★ | 31 | 0 |
| Cornerstone Care Center | 6.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fowler Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.