Fowler Health Care

Based on observations and interviews, the facility failed to store, distribute, and serve food in a sanitary manner in two of two kitchen refrigerators.Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerator and the walk-in refrigerator. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/22/26 read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for four (#4, #7, #22 and #2) of six residents reviewed for respiratory care out of 29 sample residents.Specifically, the facility failed to ensure that Resident #4, Resident #7, Resident #22 and Resident #2 received oxygen therapy in accordance with their physician's orders.Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN), Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 11/11/21, accessed on 4/20/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) Devices such as high flow oximetry masks, CPAP (continuous positive airway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#3) of two residents reviewed for hearing out of 29 sample residents.Specifically, the facility failed to follow up on a post-eligibility treatment of income (PETI) request in order to obtain a hearing aid in a timely manner for Resident #3.Findings include:I. Facility policy and procedureThe Audiology and Ancillary Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/15/26 at 12:07 p.m. It read in pertinent part, The purpose of this policy is to provide a process for identifying, arranging, and documenting audiology services for residents who need hearing-related care. The facility will provide or arrange audiology services for residents as needed and as ordered by a physician or other authorized provider, when required. Services may be provided by a licensed audiologist or through a contracted provider.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Ensure staff performed appropriate hand hygiene in the dining room while assisting residents with eating; -Ensure housekeeping staff used appropriate hand hygiene practices while cleaning the residents' rooms; and, -Ensure housekeeping staff cleaned high-touch surfaces in residents' rooms.Findings include: I. Failed to ensure staff performed appropriate hand hygiene while assisting residents in the dining roomA. Facility policy and procedureThe Handwashing policy, revised October 2025, was received from the nursing home administrator (NHA) on 4/15/26 at 4:00 p.m. The policy read, All personnel are trained on the importance of handwashing. Wash your hands after contact with the resident or in the resident's environment. The use of gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: The facility had a change of staff during the first quarter. I. Record review The PBJ stuffing report for quarter one (10/1/23 to 12/31/23) showed the following triggered area: -Failed to Submit Data for the Quarter II. Interview The nursing home administrator (NHA) was interviewed on 3/13/24 at 10:45 a.m. She said during the last quarter there had been a staff change. She said she tried to submit the data, however, it was not submitted correctly. When she went back to the system to correct the errors, she was unable to make the necessary corrections and the data was not accepted. She said she had not had any issues submitting data since the incident. She said it was important to submit the data timely and correctly.

Based on observations, record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room. Findings include: I. Facility policy and procedure The Respect and Dignity policy, revised February 2021 was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m., It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:00 a.m. to 9:00 a.m., lunch at 11:00 a.m. to 1:00 p.m. and dinner at 5:00 p.m. to 6:00 p.m. B. Resident observations and interviews On 3/11/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the provider according to physician orders for one (#28) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to notify and document Resident #28's elevated blood sugar levels to the provider as directed on the physician's order. Findings include: I. Facility policy and procedures The Hypoglycemia or Hyperglycemia policy and guidelines, revised 2011, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part, The facility would ensure medications were administered per established physician's parameters. Staff would document all labs/treatments in nurse's notes and on the medication sheets. II. Resident #28 A. Resident status Resident #28, over 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included type II diabetes mellitus, personal history of traumatic brain injury,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #2 (hired on 6/1/21), CNA #3 (hired on 10/2/21), CNA #4 (hired on 2/11/19) and CNA #5 (hired on 11/2/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interview The nursing home administrator (NHA) was interviewed on 3/12/24 at 1:30 p.m. She said she could not locate the performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews the facility failed to store, distribute and serve food in a sanitary manner in two of two kitchen nourishment refrigerators. Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerators. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to provide adequate ventilation by means of mechanical ventilation for one resident bathroom and two resident shower rooms. Specifically, the facility failed to ensure resident bathroom vents were free from lint and the exhaust fans were functioning. Findings include: I. Facility policy The Exhaust Fan and Ventilation policy, dated 1/25/24, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part, The facility would check all exhaust fans in bathrooms, shower room soiled and clean utility rooms, janitor's closets, kitchen, and sink and laundry areas and oxygen room. The facility would ensure that airflow is sufficient enough to hold a piece of paper to the vent when operating. Clean vents using vacuum and air compressor to remove all dust. II. Observation An observation of the resident environment was completed on 3/12/24 at 12:40 p.m. The exhaust fans in shower room [ROOM NUMBER] had no audible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and -The freezer temperature was below zero degrees Fahrenheit. Findings include: I. Improper hand hygiene A. Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying using individual disposable towels, a continuous towel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure staff had current abuse and dementia care training. Specifically, the facility failed to: -Ensure one of two registered nurses (RNs) reviewed received abuse prevention training and two of two received dementia training; -Ensure one of two licensed practical nurses (LPNs) reviewed received dementia training; and -Ensure two of six certified nurse aides (CNAs) reviewed received dementia management training, and one of six received abuse prevention training. Findings include: I. Training review The December 2019 staffing schedule was provided on 12/15/19 by the nursing home administrator (NHA). A sample of two RNs, two LPNs and six CNAs included on the schedule were reviewed for compliance with training requirements. Training records revealed: -RN #1 did not have dementia management training and RN #2 did not have current abuse prevention training or dementia training. -LPN #2 did not have dementia management training. -CNAs #3 did not have dementia management training oe abuse prevention training, and CNA #5 did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used, for one (#6) of two residents reviewed for assistive devices out of 16 sample residents. Specifically, the facility failed to: -Re-evaluate the ongoing use of a personal restraint; and -Develop a comprehensive care plan addressing the use of the restraint. Findings include: I. Facility policy and procedure The Restraint policy, revised April 2017, provided by the director of nursing (DON) on 12/17/19 at 2:33 p.m., included: restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been unsuccessful. Restraints shall only be used to treat the resident's medical symptoms and never for the discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least resistive alternative will be used for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days for one (#33) of five residents reviewed for unnecessary medications out of 16 sample residents. Specifically, the facility failed to discontinue a PRN psychoactive medication after 14 days without a physician's rationale for Resident #33. Findings include I. Resident #33 status Resident #33, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety and insomnia. According to the 11/16/19 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident had no mood symptoms. The resident had behaviors directed towards others and refused care. II. Record review The care plan, initiated 3/4/05 and revised 11/16/19, identified the resident would be prescribed the lowest effective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.