Fountainview Ctr For Alzheimer

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled Behavior Tracking last revised 02/05/04 revealed, Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. Purpose: the purpose of behavior tracking is to provide insight into the behavioral symptoms of our residents by tracking all behavioral occurrences during a determined period. Review of the facility's policy titled,…

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, 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. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 04/04/22 revealed .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: . iii. Provide appropriate, pressure-redistributing, support surfaces; . Review of the facility's policy titled, Turning & Repositioning, dated 01/30/05 revealed 1. A resident that is identified either by a staff member or through the assessment process as having mobility limitations will be assisted, turned and/or…

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, 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. Findings include: Review of R5's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted R5 on 05/18/21 with diagnoses including dementia, and chronic pain. Review of R5's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/15/25, documented R5 was severely cognitively impaired and was on opioid medication. R5 did not receive nonpharmacological interventions for pain. Review of R5's Care Plan for, initiated 04/29/25 and located in the resident's EMR under the Care Plan tab revealed [R5] pain related to OA [osteoarthritis] right shoulder, chronic pain, radicular pain right arm, peripheral neuropathy, rheumatoid arthritis. The Care Plan interventions included Administer medications as…

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 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. Findings include: Review of the facility's policy titled Infection Prevention and Control Program dated 01/09/25 revealed . 4. Antibiotic Stewardship, a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. b. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. c. Antibiotic usage is evaluated and…

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, 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. Findings included: Review of the policy titled, Storage, dated March 2018, indicated Refrigerated Storage 1. Store perishable food in refrigerator and/or foods marked 'Keep Refrigerated' by the manufacturer . 3. Use FIFO [first in first out] when stocking and rotating shelves. Review of the policy titled, Routine Cleaning Programming Rooms, dated 6/1/2016, indicated the policy of (the facility) is to ensure the provision of routine cleaning in order to provide a safe environment in all Programming Rooms . 3. Routine surface cleaning will be conducted with detailed focus on visibly soiled surface and high touch areas to include, but not limited to: .…

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 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. Findings included: Review of facility documents provided by the Administrator revealed a lack of a water management program to monitor and prevent the growth of opportunistic water-borne pathogens. Interview on 1/18/2024 at 11:39 am, the Maintenance Director confirmed the facility did not have a documented water management system in place to prevent the growth of Legionella in the facility. The Maintenance Director stated Legionella was a bacterium that grew in water, and he was aware of the areas in the building that needed to be checked for Legionella, such as showers and sinks not in use in resident rooms. The Maintenance Director indicated he was running water in the vacant resident room showers monthly but did not document it in his electronic maintenance software program.…

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 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. Findings include: Review of the facility's policy titled, Advance Beneficiary Notices, dated 2/1/2018, revealed it is the policy of the [name] center to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines: Number 4. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides: Number…

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, 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. Findings include: Review of the policy titled Comprehensive Care Plans, dated 9/1/2023, documented the policy of [name of facility] is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychological needs that are identified in the resident's comprehensive assessment. Review of the clinical record revealed R53 was admitted to the facility on [DATE] with diagnoses that included hemiplegia…

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, 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. Findings include: Review of the facility's policy titled Range of Motion, dated 9/15/2004, indicated Purpose: [name of facility] is committed to ensuring that each resident reaches and maintains his or her highest level of range of motion and to preventing avoidable decline in range of motion (ROM). Implementation of this program is to maintain joint mobility and muscle strength, minimize contractures, increase strength and activity tolerance, reduce pain and minimize complications of mobility. Adequate preventive care may include and the application of splints and braces when appropriate. Review of the clinical record revealed R53 was admitted to the facility on…

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.