Fountain Circle Care & Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were permitted to share a room with their spouse when both residents resided in the facility and both consented, for 2 of 2 sampled residents reviewed for roommate change, Resident (R)2 and R77. Although R2 and R77 had been married for 66 years and expressed the desire to reside together, there was no documented evidence the facility made reasonable efforts to accommodate the married couple's request prior to the Surveyor's intervention. This failure resulted in prolonged separation and psychosocial distress for both residents.

Inspectors wroteBased on interview, record review, and review of facility's policy, the facility failed to ensure pain management was provided consistently with professional standards of practice for 1 of 4 sampled residents reviewed for pain management, Resident (R)152. The facility failed to assess, monitor, and timely intervene for uncontrolled post-surgical pain following R152's admission to the facility on [DATE] after surgical repair of a right distal femur fracture. These failures resulted in R152 experiencing uncontrolled pain requiring Emergency Medical Services (EMS) transfer to the hospital Emergency Department (ED) for further evaluation and treatment. Additionally, R152 sustained a fall on 02/16/2026 and the Nurse Practitioner (NP) ordered an MRI of the lumbar and thoracic area due to increased pain. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to prepare and serve food in accordance with professional standards for food service safety. This had the potential to affect all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, review of the Quality Assurance/Quality Assurance and Performance Improvement (QA/QAPI) Committee minutes, and review of the facility's Plan of Correction (PoC), the facility failed to maintain a QA/QAPI Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeat deficiencies related to the facility's failure to ensure there was an effective pain management program and infection control program. The facility failed to thoroughly perform an audit process, and the QAPI Committee failed to provide effective oversight and follow-up of identified concerns. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 sampled residents reviewed for infection control, Resident (R)71.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to promote and facilitate resident self-determination through support of resident's choice related to getting out of bed for 1 of 3 sampled residents investigated for resident choices, Resident (R) 7.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide services to dependent residents to maintain good personal hygiene for 1 of 25 sampled residents investigated for activities of daily living (ADL's) care, Resident (R) 6.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with the physician's orders and professional standards of practice for 2 out of 4 sampled residents investigated for respiratory care, Resident (R) 6 and R48.

Inspectors wroteBased on observation, interview, review of facility policy, and review of manufacturer's recommendations, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication refrigerators reviewed, Hall B refrigerator.

Inspectors wroteBased on interview and review of the facility's policy, the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. This affected all 125 current residents in the facility. During a group interview on 03/05/2025 the Resident Council members stated they did not receive mail on Saturdays. In an interview with the Assistant Business Office Manager (ABOM) and the Administrator on 03/06/2025, it was confirmed that mail delivered from the Post Office to the facility on Saturday after 5:00 PM was not sorted or delivered by staff until the following Monday.

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the website www.drugs.com, review of medication package inserts, and review of the facility's policy, the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in 3 out of 3 medication refrigerators, and 2 out of 5 medications carts, affecting 25 residents, Resident (R) 17, R11, R17, R19, R21, R23, R25, R36, R37, R38, R45, R46, R47, R52, R58, R61, R62, R68, R79, R92, R98, R117, R229, R230, and R231. [...]

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to notify the resident and/or the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights, and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 4 of 5 residents investigated for hospitalizations, Resident (R) 25, R47, R90, and R110.

Inspectors wroteBased on observation, interview, review of a Centers for Medicare and Medicaid Services (CMS) memorandum, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 40 residents reviewed for infection control, Resident (R) 68 and R45. The facility also failed to conduct an annual review of their IPCP. Observation of R68's wound care revealed Registered Nurse (RN) 1 failed to wear a gown while performing it, and the resident's door did not have an Enhanced Barrier Sign (EBP) sign posted. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives services in the facility with reasonable accommodation of resident needs for two (2) of twenty-eight (28) sampled residents (Residents #25 and Resident #69). Observation on 12/17/19 and 12/19/19, revealed Resident #25 and Resident #69's call lights were out of reach and inaccessible to the residents.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to submit the Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one (1) of twenty-eight (28) sampled resident's (Resident #1). Review of the CMS Submission Final Validation Report, dated 12/12/19, revealed the facility failed to submit Resident #1's Annual MDS Assessment with an Assessment Reference Date of 09/26/19, within the required timeframe.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Observation of the Medication Cart One (1) D Wing, on 12/18/19, revealed one (1) vial of Lantus Insulin, with an open date of 11/08/19 and an expiration date of 12/06/19; and one (1) vial of Humalog U-100 Insulin, with an open date of 11/09/19 and an expiration date of 12/07/19.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-eight (28) sampled residents (Resident #59). Observation on 12/17/19, during initial tour of D-Wing and subsequent observations on 12/17/19, revealed Resident #59's suprapubic catheter urinary drainage bag was lying on the floor.