Fountainview Ctr for Alzheimer

Inspectors wroteBased on interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure residents were free from sexual abuse for three of six residents reviewed for abuse (Resident (R) 2, R3, and R6). Specifically, R1 displayed inappropriate sexual behaviors towards others on 6/20/2025 when she grabbed a male housekeeper's private area (groin) and buttocks. The resident's inappropriate sexual behavior towards staff members progressed to resident's on the South Pavillion unit sustaining sexual abuse. Even though the facility was aware of R1's inappropriate sexual behavior and her abuse of other residents, the facility failed to implement any interventions to protect the residents who resided on the unit. [...]

Inspectors wroteBased on interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to complete a thorough investigation which included interviewing and/or assessing other residents who resided on the South Pavillion unit and interviewing staff who worked on the unit for two of two abuse investigations involving residents (Resident (R) 1, R2, and R3). Also, during the facility's investigation, the Administrator who was the Abuse Coordinator failed to thoroughly investigate and identify Certified Nurse Aide (CNA) 2's failure to protect R3 when she discovered R3 in R1's room with his pants off; instead of intervening, the CNA left the resident's room and reported her observations to the nurse. [...]

Inspectors wroteBased on interview, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to revise the resident's care plan with nonpharmacological interventions for inappropriate sexual behavior for one of nine sampled residents (Resident (R) 1). This failure led to multiple residents on the South Pavillion unit being victims of sexual abuse by R1. Cross Reference: F600 Free from Abuse and Neglect. The facility's failure to ensure R1's care plan was revised with interventions protecting residents from sexual abuse had caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy was identified on 8/15/2025 and was determined to exist on 6/20/2025. R1's care plan focus was revised to identify the problem of the resident engaging in inappropriate sexual behavior; [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure targeted behaviors and potential side effects were monitored for administered psychotropic medications for one of five residents (Resident (R) 82) reviewed for unnecessary medications out of 24 sampled residents. This had the potential for unwarranted medication use and for adverse reactions due to potentially unnecessary medications.

Inspectors wroteBased on observations, resident family and staff interviews, record review, and policy review, the facility failed to prevent and provide treatment for one resident (Resident (R) 91) of three sampled residents reviewed for pressures ulcers out of 24 sampled residents. This failure had the potential for R91's sacrum wound to delay healing and/or worsen.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure nonpharmacological interventions were implemented for one of 24 sampled residents (Resident (R) 5). This failure placed the resident at risk for unmanaged pain and at risk for unnecessary medication use.

Inspectors wroteBased on record review, staff interviews, facility policy review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the McGreer criteria for antibiotic use for urinary tract infections (UTIs), the facility failed to maintain a functional Antibiotic Stewardship Program that ensured an antibiotic prescribed and administered met the McGreer criteria and CDC guidance for one of two residents (Resident (R) 95) residents reviewed for antibiotic stewardship out of a total sample of 24 residents. This had the potential for the development of antibiotic-resistant organisms.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy, the facility failed to ensure daily nursing staffing data was posted and reflected the current staffing hours for three of four days of the survey. This deficient practice had the potential to adversely affect all residents and/or resident representatives by not being able to view the facility staffing levels.

Inspectors wroteBased on observations, interviews, record review, and review of the policy titled Pressure Injury Prevention and Management, the facility failed to implement pressure injury interventions to prevent the development of unstageable pressure ulcers for two of five sampled residents (R) (R37 and R98) reviewed for pressure ulcers; failed to conduct weekly skin assessments of R98's left hip DTI (deep tissue injury) and document treatments to R98's left hip for 10 days. Harm was identified to occur on 9/6/2023 for R37 when an unstageable DTI developed on the right heel, and then increased to a Stage 3 pressure ulcer. In addition, harm was identified to occur on 1/1/2024 when the facility failed to transcribe wound care orders for R98, resulting in the development of a DTI to the left hip, which after debridement developed into a Stage 4 pressure ulcer.

Inspectors wroteBased on observations, interviews, manufacturer instruction review, and review of facility policies, the facility failed to discard containers of buttermilk with expired manufacturer's expiration dates, failed to date nutritional supplements when removed from freezer storage and when opened, and failed to clean drawers that contained food products. These failures had the potential to affect all 114 residents who resided in the facility.

Inspectors wroteBased on documentation review and staff interviews, the facility failed to have a documented water management program that included measures to monitor and prevent the growth of opportunistic water-borne pathogens. This had the potential to affect all 114 of 114 residents that resided at the facility.

Inspectors wroteBased on record review, staff interview, review of Medicare Advanced Beneficiary Notice (ABN) instructions, and policy review, the facility failed to ensure each resident receiving skilled services under Medicare Part A whose services were being terminated received the appropriate form, Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) Medicare Form 10055, indicating termination date and appeal options for two of three residents (R) R86 and R20, reviewed for Beneficiary Notices.

Inspectors wroteBased on observations, interviews, record review, and review of the policy titled Comprehensive Care Plans, the facility failed to implement the comprehensive person-centered plan of care for one two residents (R) (R53) reviewed for restorative rehabilitation services. The facility's failure to apply a hand splint to R53's contracted left hand as directed in the resident's plan of care placed the resident at risk of development of worsening contractures.

Inspectors wroteBased on observations, interviews, record review, and review of the policy titled Range of Motion, the facility failed to apply a left-hand splint to prevent further contractures, as ordered for one of two residents (R) (R53) reviewed for limited range of motion and contractures. This failure had the potential to cause R53's contractures to worsen.