Fountainbleau Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected one resident (Resident #22) outside of the 22 sampled residents and had the potential to affect all residents in the facility. The facility's census was 105. Review of the facility's policy, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, showed: - Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard; - Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #74) out of 22 sampled residents was free from abuse when an employee knowingly sent inappropriate sexual pictures and text messages to the resident. The facility census was 105. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed: - Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for three residents (Residents #3, #8, and #67) out of 22 sampled residents and one resident (Resident #36) outside the sample. The facility's census was 105.1. Review of Resident #3's medical record showed: - admission date of 11/14/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #3, #67, and #96) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 105. The facility did not provide a policy on trauma informed care. 1. Review of Resident #3's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation of the controlled medications and to ensure nursing staff signed at the beginning and the end of each shift for four medication carts out of five sampled medication carts. The facility's census was 105. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed:- Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count;- The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear proper personal protective equipment (PPE) and to maintain infection control practices to prevent the development and transmission of infection during suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen and into the bladder to drain urine outside of the body and into a bag) care for one resident (Resident #5) out of one sampled resident, and during wound care when the marker and scissors weren't cleaned and put back into and taken out of the staff's pocket for one resident (Resident #26) out of one sampled resident. The facility failed to ensure staff maintained appropriate hand hygiene practices during medication pass for three residents (Residents #23, #32 and #35) out of seven sampled residents. The facility's census was 105. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 105. The facility did not provide a policy for overbed lighting safety. 1. Observation on 02/09/26 at 1:36 P.M. of room [ROOM NUMBER] showed a framed photo collage on top of the light fixture above the bed by the window. 2. Observation on 02/09/26 at 1:40 P.M. of room [ROOM NUMBER] showed a poster, a license plate, and a framed picture on top of the light fixture above the bed by the window. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions), and abuse/neglect training and provide at least twelve hours of nurse aide in-service education per year. This affected three of three sampled Certified Nurse Aides (CNAs). The facility census was 105. Review of the facility's policy, In-service Training, Nurse Aide, revised August 2022, showed:- All personnel are required to participate in regular in-service education. Participation in in-service education is considered working time for which personnel are paid their regular wages;- In-service training is based on the outcome of the annual performance review;- Annual in-services: ensure the continuing competences of nurse aides; are no less than 12 hours per employment year; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected two residents (Resident #13 and #23) outside of the 19 sampled residents and had the potential to affect all residents in the facility. The facility census was 95. The facility did not provide a policy regarding environment. 1. Observation on 09/24/24 at 11:44 A.M. of the 300 and 400 halls showed the halls with a strong urine odor. 2. Observation on 09/26/24 at 3:45 P.M. of the south shower room showed: - A used razor on the shower room floor; - A brown slimy substance caked around the shower drain; - Part of the shower room floor rotten with exposed layers of subfloor showing; - Dingy tile with dirty, black grout under the hand rail; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected four residents (Resident #17, #45, #73 and #88) out of 19 sampled residents and three residents (Resident #25, #69, and #199) outside the sample and had the potential to affect all residents. The facility's census was 95. Review of the facility's policy entitled, Pest Control, revised July 2023, showed: - The facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; - Windows are screened at all times; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their background screening policy regarding screening staff members for the Family Safety Care Registry (FCSR), Employee Disqualification List (EDL), Criminal Background Check (CBC), and Nurse Aide (NA) Registry prior to the employment start date for three out of ten employees reviewed. The facility census was 95. Review of the facility's policy titled, Nurse Aide Registry Verification, revised August 2022, showed: - Certified nurse aide (CNA) licenses shall be verified through the state registry of nurse aides before individuals may serve as nurse aides or nursing assistants; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility census was 82. Record Review of the facility's Guideline & Procedure Manual, dated 2016, showed: - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions; - Items cleaned after each use include can opener, small food preparation equipment (e.g. blender, food processor), slicer, kettles and utensils, mixers, cutting boards, work tables and counters, beverage table, coffee urns, pots and pans, dishes, dining room tables and chairs; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance Performance Improvement (QAPI) committee meetings with the required members. The facility's census was 82. Record review of the facility's QAPI Program policy, revised February 2020, showed: - This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; - The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements; - The QAPI committee reports directly to the administrator; - The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. Record review of the facility's 2023 QAPI Plan showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from May 2022 to April 2023. The facility census was 82. Record Review of the facility's Resident Trust Fund Bond Policy, undated, showed: - A Nursing Facility or Resident/Patient Trust Fund Bond is required by long-term care facilities, including nursing homes and assisted living facilities, along with businesses that offer at-home care; - The surety bond protects long-term care patients and their families by ensuring that the facility complies with state laws and regulations and administers patient trust funds in an ethical and financially responsible manner; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for two residents (Resident #34 and #185) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 at least two days before coverage ended for two residents (Resident #34 and #185) out of three sampled residents. The facility's census was 82. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for three residents (Resident #5, #25, and #39) out of 18 sampled residents. The facility census was 82. Record review of the facility's policy, Preparing the Resident for Transfer or Discharge, revised December 2016, showed: - Residents will be prepared in advance for discharge; - Business office is responsible for informing the resident, or his/her representative of our facility's readmission appeal, rights, bed-holding policies and etcetera; - Nursing services is responsible for completing a discharge note in the medical record and directing the resident or representative to the business office prior to the transfer or discharge. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required time frames for one resident (Resident #7) out of 18 sampled residents and 10 residents outside the sample (Resident #2, #6, #28, #45, #47, #54, #61, #63, #67, and #71). The facility's census was 82. Record review of the facility's policy, Resident Assessments, revised March 2022, showed: - A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements; - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments - conducted for all residents in the facility: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility) within the required timeframe for two residents (Resident #7 and #49) out of 18 sampled residents and six residents (Resident #2, #28, #45, #47, #52, and #54) outside the sample. The facility's census was 82. Record review of the facility's policy, Resident Assessments, revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments - conducted for all residents in the facility: Quarterly Assessment; - The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Data Set assessments (MDS - a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for three residents (Resident #5, #7, and #49) of 18 sampled residents and ten residents outside the sample (Resident #2, #6, #28, #45, #47, #52, #54, #61, #63, and #71). The facility's census was 82. Record review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following: - Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2+14 days); - Entry tracking records must be transmitted electronically no later than the entry date + 14 days; [...]