Fountains Rehabilitation at Mill Cove

Inspectors wroteBased on observations, interviews and record review, the facility failed to store and label food items in a manner to prevent foodborne illness and maintain sanitary conditions, by failing to appropriately date mark food items in the dry storage area and nourishment rooms. This deficient practice had the potential to affect all residents who receive food and nourishment items prepared and/or stored by the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation to confirm that each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for three (Residents #49, #998 and #999) of three residents whose Beneficiary Notices were reviewed.

Inspectors wroteBased on record review, interviews and a review of facility policies and procedures, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, by failing to monitor and track infections properly between August 2025 and February 2026. This failure can contribute to preventable diseases spreading rapidly, resulting in widespread resident illness with potentially fatal outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement its admissions policy for one (Resident #5) of six residents reviewed for admission agreements.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that reflected the resident's individualized needs for one of (Resident #10) of 21 residents whose care plans were reviewed. Resident #10 had no care plan addressing his vision problems and although he had been referred to an ophthalmologist more than once in 2024 (January and May) for cataract surgery, the facility did not follow through until February of 2025. An interview with the resident revealed this negatively affected his mood and he felt trapped.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #10) of 2 residents reviewed for vision abilities/status from a total survey sample of 21 residents, received proper treatment and assistance in making appointments and arranging for transportation to and from the office of a practitioner specializing in the treatment of vision impairment or the office of a professional specializing in the provision of vision assistive devices to maintain vision abilities.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that 1) It posted daily, at the beginning of each shift, the facility name, current date, the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, as well as the resident census on two (2/8/26 and 2/9/26) of five days during the recertification survey.

Inspectors wroteBased on observations, interviews and a review if facility policies and procedures, the facility failed to maintain its equipment in safe operating condition, by failing to ensure lint was promptly removed from facility dryers. Leaving lint in a dryer trap creates a severe fire hazard, as accumulated lint easily ignites from the heating element, potentially causing a fire that can place staff, residents and other facility occupants in danger. It also restricts airflow, which can lead to overheating.

Inspectors wroteBased on observations, staff interviews, and medical record review, the facility failed to ensure that a resident in a long term care nursing facility, who was identified with a MD/ID (Mental Disorder/Intellectual Disability) and/or other related conditions was re-evaluated to determine if specialized care and services were required, in the most integrated setting appropriate to their needs, for one resident (Resident #29) in a total sample of 20.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide one (Resident #25) of a total sample of 20 residents, with necessary services to maintain appropriate grooming and personal hygiene, by failing to provide timely nail care per the resident's comprehensive care plan.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that two (Residents #227 and #31) of 30 sampled residents, were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Resident #227, who was continent of bowel per interview with nursing management, was told to soil her brief and the CNA would clean her up afterward. Resident #31's CNA turned off his call light and did not return to provide care until prompted by his nurse, approximately three hours later. At that time the CNA told the resident he lied about her and she was not going to speak to him.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure one (Resident #74) of four residents reviewed, from a total sample of 30 residents, received medication as ordered by the physician. On 4/25/22 at 12:06 p.m., Resident #74 stated she took lithium daily and had not received the medication for the last five days. A review of Resident #74's medical record revealed that she was admitted on [DATE] with diagnoses including insomnia, anxiety disorder and bipolar disorder. A review of the admission Minimum Data Set (MDS) assessment, dated 4/13/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adminster tube feedings as ordered by the physician for one (Resident #44) of one resident reviewed for compliance with enteral nutrition from a total of 30 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide oxygen at the prescribed flow rate for one (Resident #31) of 19 residents receiving respiratory treatments from a total of 30 residents in the sample.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on four errors out of 30 opportunities for error, resulting in a facility error rate of 13.33%, and involving Residents #59, #6, #23, and #228.