Fountain Manor Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for three Residents (Resident #19, Resident # 28, and Resident #98) out of 16 residents receiving oxygen therapy. As evidenced by the Residents' oxygen concentrators were not delivering the oxygen at the prescribed flow rate. There were 134 residents residing in the facility at the time of the survey. The findings included.Resident #19During an observation on 05/18/2026 at 8:04 AM Resident #19 was in bed awake, oxygen (02) running at 1.5 liters Per Minute (LPM) via nasal Canula (NC), no distress noted.Observations on 05/19/2026 at 9:09 AM Resident#19 was observed sitting up in bed and on 05/20/2026 at 7:27 AM Resident # 19 was in bed with eyes closed and 02 via NC running at 2 LPM, no distress noted.On 05/19/2026 at 9:09 AM, Resident #19 was observed sitting upright in bed. On 05/20/2026 at 7:27 AM, the resident was noted to be in bed with eyes closed. During both observations, oxygen was…

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, interviews and record review the facility failed to protect the residents right to be free from physical abuse for one (Resident #1) out of three sampled residents as evidenced by a federal report submitted by the facility regarding a verified allegation of physical abuse from a staff member towards Resident #1. There were 130 residents residing in the facility at the time of survey.The findings Included: On 7/22/25 the facility submitted a federal report [] alleging Resident #1 was physically abused by Mental health technician, Staff A. On 7/28/25, The facility verified the allegation and terminated Staff A's employment.On 07/28/2025 Resident #1 was observed seated on the patio in stable condition.On 7/28/25 at 9:55 AM Resident#1 was interviewed (translated by other surveyor on the team) about the allegation and stated, I am pleased with the staff except one person. That staff hit me, I fell to the floor, and he dragged me to my room. Record review of Resident #1's demographic sheet…

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, reviews and interviews, the facility's staff failed to notify one (Resident #1) out of three sampled resident's family /representative of a change in condition; as evidenced by Resident #1 had a fall and a progress note written the day of the incident, indicated no next of kin was listed to be notified. The findings included: On 6/16/25 at 1:15 PM Resident#1 was observed seated in the dining area amongst other residents. Resident#1 did not respond when greeted by surveyor. On 6/17/25 at 10:35 AM Resident#1 was observed seated in wheelchair on the patio with staff supervising. Resident #1 stated: Sometimes I have racing thoughts, and I have to calm myself down . Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: abnormalities of gait and mobility, lack of coordination and seizures. Record review of a Quarterly Minimum Data Set (MDS) reference dated 5/14/25 indicated Resident #1 is severely impaired…

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, interviews and record review the facility failed to properly store medications in one out of two treatment carts as evidenced by an observation of an unlocked unattended medication/treatment cart. There were 131 residents residing in the facility at the time of the survey. The findings included: On 6/16/25 at 12:59 PM, observation on the 300's hallway revealed an unlocked, unattended medication/treatment cart. The surveyor knocked on the nearest room door and inquired if the assigned nurse was inside the room. On 6/16/25 at 1:09 PM Staff A, wound care nurse exited the room, returned to cart and was notified about the observation and asked about protocol Staff A stated: The cart should always be locked when unattended. Also stated I was helping a resident and left it unlocked by mistake. Interview on 6/18/25 at 10:34 AM, the Director of Nursing revealed: The cart should be locked when unattended. Review of a Policy titled Medication Labeling and Storage 2001 Med Pass, Inc. revealed Policy statement: The facility stores all medications and biologicals in locked…

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 provide catheter care according to professional standards for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care as evidenced by two observations of incorrect indwelling urinary catheter care being provided. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2 's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. Staff D,CNA drained the catheter bag and cleansed the tip of the catheter bag with [Germicidal Disinfectant Wipes]. Staff D, CNA washed her hands at the bedside with the residents soap [brand body wash] that was personally selected by Staff D, CNA to be used. Staff D, CNA cleaned the outer perineum area first, then the inside labia and lastly the catheter in a top to bottom motion. Review of…

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 reduce the risk of Urinary Tract Infections for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care, as evidenced by staffs' failure to implement infection prevention and control precautions during perineal care for Resident #2 and Resident #3 with indwelling urinary catheter. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. Staff D,CNA drained the catheter bag and cleansed the tip of the catheter bag with [Germicidal Disinfectant Wipes]. Staff D, CNA washed her hands at the bedside with the residents soap [brand body wash] that was personally selected by Staff D, CNA to be used. Staff D, CNA cleaned the outer perineum area first, then the inside…

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 observation, interview, and record review the facility failed to ensure the safety of a vulnerable Resident (Resident #32) out of 29 sampled residents. As evidenced by disposable shaving razors were observed at the resident's bedside. There were 133 residents residing in the facility at the time of the survey. The findings Included: On 11 /12/24 at 09:05 AM and on 11/12/24 at 01:00 PM shaving razors observed on Resident #32's bedside table. On 11/14/24 at 09:10 AM three (3) shaving razors were observed on the resident's bedside table. Review of Resident #32's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Paranoid schizophrenia and Bipolar disorder. Review of the Physician's Orders Sheet for November 2024 revealed Resident #32 had orders that included daily medications for Schizophrenia and a medication three times a day for Anxiety. Review of Resident # 32's Schedule 5 Day Minimum Data Set (MDS) dated [DATE] indicated in…

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 observation, interview and record review the facility failed to follow infection control standards for one (Resident #103) out of 29 sampled residents. As evidenced by Resident# 103's nebulizer and oxygen tubing were not protected in a bag/covering on the residents bedside table. The findings Included: During observation on 11/12/24 at 08:43 AM, Resident #103 was asleep in bed and the nebulizer and tubing were not in a protective bag/covering on the bedside table. Review of the medical records for Resident #103 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic respiratory failure with hypoxia. Chronic Obstructive Pulmonary disease. Review of the Physician's Orders Sheet for November 2024 revealed, Resident #103 had orders that included but not limited to: Ipratropium-Albuterol solution via nebulization three times a day for Chronic Obstructive Pulmonary disease. Record review of Resident #103 's admission Minimum Data Set (MDS) dated…

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 interview, the facility failed to implement policies and procedures for ensuring timely reporting of abuse or mistreatment for three out of three sampled residents (Residents #4, 5, and #8). There were 98 residents residing in the facility at the time of the survey. The findings included: Review of facility's abuse log noting Abuse, neglect, Mis-Management of Funds, Incidents of Unknown Origin log from January 2023 to October 2023 revealed: On February 18, 2023, at 11:15 AM, an incident or altercation happened between Resident #4 and Resident #8. Further review showed that the facility reported the incident to the Agency for Healthcare Administration (AHCA) Immediate Report system on February 20, 2023, at 03:07 PM. Review of the facility's incident report revealed that Staff A, Registered Nurse (RN), was aware of the incident on February 18, 2023, at 10:50 AM and reported it to the Director of Social Worker and the Director of Nursing (DON) on February 20, 2023 at 09:45 AM. During an interview with the Director of Social Worker on 10/30/2023 at 11:37 AM…

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 interview and record review, the facility failed to honor the resident's choice of food for one (Resident #109) out of three residents investigated for food. This deficient practice has the potential to limit the residents' right to make personal dietary choices. The facility had a census of 136 residents at the time of this survey. Findings included: During an interview on 06/26/23 at 10:36 AM, Resident #109 stated, I don't like the food. I used to get boiled eggs, but now they changed it to scrambled eggs. I don't like scrambled eggs; I preferred boiled egg. I never eat scrambled or fried eggs. They can see that I never eat their eggs. During an interview on 06/28/23 at 09:18 AM with Staff B, a CNA (Certified Nursing Assistant), regarding resident's food choices, Staff B stated, as CNAs, they don't really know about the residents' diet. They only go and set up the food for the residents; however, the residents always have options when they give them the food. They can call the kitchen or let them know if they don't like the food, so they can bring something else. Staff B…

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.