Fountain Bleu Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to date medication when opened in two (400B and 500B) of four medication carts reviewed for medication storage. Findings include:On [DATE] at 10:04 AM, during review of the storage in medication cart 400B with Licensed Practical Nurse (LPN) B, Latanoprost Opthalmic Solution was observed with an open date of [DATE], expired 30 days beyond the opened date. Further review of the storage in medication cart 400B, Fluticasone/ Salmeterol Diskus, and two tubes of Biofreeze Topical Gel, was observed without opened dates.On [DATE] at 10:10 AM, LPN B was queried and revealed the Latanoprost should be discarded, and the other opened medications should have been dated when opened.On [DATE] at 10:15 AM, during review of the storage in medication cart 500B with LPN C, ProSource Plus was observed with an opened date of [DATE], expired 30 days beyond the opened date. Further review observed Milk of Magnesia with an opened date of [DATE], 30 days beyond the…

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 resident rooms had signage alerting of Enhance Barrier Precaution (EBP-precautions used to reduce the spread of infection for residents with medical devices or wounds) notices for two residents (R30 and R99) reviewed for infection control. Findings include:R30A review of R30's medical record revealed that R30 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Esophagitis. A review of R30's Minimum Data Set (MDS) assessment dated [DATE] noted, R30 with an intact cognition and required assistance to complete activities of daily living. R30's MDS noted, the presence of one stage three pressure ulcer (full-thickness skin loss, exposing the fatty tissue beneath) and one venous and arterial ulcer present. A review of the physician order revealed, Cleanse Right posterior lower leg open area with normal Saline, Pat Dry, Apply Xeroform gauze and Cover with ABD pad and Paper tape every day shift every Mon,…

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 This citation pertains to Intake MI00152110. Based on observation, interview, and record review, the facility failed to implement a fall intervention for one resident (R704) out of one reviewed for falls. Findings include: On 4/15/2025 at 10:24 AM, R704 was observed laying in bed. R704 was noted to have fall mats on the side and was in a low position. R704 stated they had no complaints about the care in the facility and were about to get some sleep because they were up all night. A review of the medical record revealed R704 was admitted into the facility on [DATE] with the following medical diagnoses, Cerebral Infarction and Muscle Weakness. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 10/15 indicating an impaired cognition. R704 also required staff assistance with bed mobility and transfers. Further review of the Incident and Accident (I/As) for R704 noted they had falls on the following days within the last six months: 11/1/2024, 11/8/2024,…

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 implement dietary care plan interventions for one residents (R22) out of two reviewed for care plans. Findings include: R22 On 8/13/2024 at 12:41 PM, R22 was observed in their room eating lunch. R22's meal ticket stated, No straws. R22 was observed to have a cup of water dated 8/13/2024 with a straw in it. A review of the medical record revealed that R22 admitted into the facility on [DATE] with the following diagnoses, Dysphagia and Multiple Sclerosis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R9 also required staff assistance with bed mobility and transfers. Further review of R22's diet order noted the following, Order: Regular diet, Mechanical Soft texture, thin consistency. Directions: No straws for nutrition. Status: Active A review of the nutrition care plan revealed the following intervention, Provide regular diet, mechanical soft…

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 observation, interview and record review, the facility failed to revise an individualized, person-centered care plan for one resident (R8) of two residents reviewed for care plans. Findings include: On 8/14/24 at 11:39 AM, R8 was observed lying in bed asleep on a perimeter mattress without heel protectors. A review of R8's medical record revealed R8 was admitted into the facility on 2/25/2020 with diagnoses which included Alzheimer's Disease, Hypertension, and Muscle Weakness. Further review revealed the resident was significantly cognitively impaired, and required one person assistance for bed mobility. Further review of R8's medical record revealed the following care plan, Actual Pressure Ulcer Formation Related to: Resident was admitted with or has pressure ulcer, with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility and bowel/ bladder incontinence daily. Resident has pressure ulcer/ wound Left Foot. Update 11/21/22 Resident has history of PVD (peripheral vascular disease). Vascular…

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 three residents (R11, R13, R64) of three residents reviewed, call lights were accessible. Findings include: R11 A review of the facility record revealed R11 admitted into the facility on [DATE]. R11's relevant diagnoses include vascular dementia, muscle weakness, diabetes, psychotic disorder, and failure to thrive. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 00/15 indicating an severely impaired cognition. A review of R11's care plan indicated they required a two-person assist for bed mobility. On 8/13/2024 at 11:50 AM, an observation revealed the call light was hanging, tied to the left bed assist rail, touching the floor. On 8/14/2024 at 10:47 AM, an observation revealed R11's call light was tied to the left bed assist bar, hanging, touching the floor, out of resident reach. Head of bed was elevated to 90 degrees, R11 was awake and conversant. An inquiry of resident to press…

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 This citation pertains to Intake: MI00145063. Based on observation, interview, and record review, the facility failed to implement care plan interventions for two residents (R706 and R708), of four residents reviewed for falls. Findings include: R706 On 6/18/24 at 9:34 AM, R706 was observed lying in bed on a regular mattress, bed low to the floor, with one floor mat on the right side of the bed. R706's face was observed with bruising under both eyes. R706 was asked what happened to cause the bruising. R706 stated, I fell. R706 was asked how they fell and explained they fell out of bed. Further observation noted, R706's call light at the foot of the bed, hanging through the frame of the bed. On 6/18/24 at 11:52 AM, R706 was observed in the same condition as above at 9:34 AM. A review of R706's medical record noted, R706 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction, unsteadiness on feet, repeated falls, and history of falling. A review of R706's care plan noted, Focus: At risk for…

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 This citation pertains to Intake MI00145063. Based on observation, interview, and record review the facility failed to secure medications on three of three medication carts throughout the facility. Findings include: On 6/18/24 at 9:30 AM, an unlabeled medication cart (#1) was observed unlocked and unattended in a hallway containing resident rooms. An unknown staff member walked by and locked it 9:32 AM. On 6/18/24 at 11:42 AM, an unlabeled medication cart (#2) was observed unlocked and unattended in hallway containing resident rooms 501-509. On 6/18/24 11:45 AM, an unlabeled medication cart (#3) was observed unlocked and unattended outside resident room [ROOM NUMBER]. When an unidentified nurse was asked about the unlocked cart they stated, I know, that's my mistake. A request was made for the facility's medication cart policy. The facility provided the Centers for Medicare and Medicaid Services form (CMS-20089) titled Medication Storage and Labeling. The form noted, Medications and biologicals in medication…

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 observation, interview, and record review, the facility failed to ensure resident food items were dated, failed to maintain kitchen equipment in a sanitary manner, and failed to ensure proper sanitization of dishware. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/10/23 between 8:45 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) A, the following items were observed: In the Anna's Place kitchenette, the gasket on the Aladdin reach-in cooler was observed to be heavily soiled with a black substance. DM A stated the gasket would be replaced. Inside the Aladdin reach-in cooler, there was an undated box of pizza, an undated sub sandwich, an undated container of cut fruit, an undated container of hummus, 2 stale, undated peanut butter and jelly sandwiches, and a cup of chili dated 4/2023. DM A confirmed the items should have been dated. Review of the facility's policy Safe Storage for Food Provided by Families dated 3/8/21 noted: 3. Each item will be clearly labeled with the…

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 psychotropic medication orders for Ativan (lorazepam) and Xanax (alprazolam) had a 14 day stop date for four residents (R19, R49, R54, R187) of five whose psychotropic medications were reviewed resulting in the potential for unintended use beyond 14 days, unnecessary use and decreased monitoring and assessment. Findings include: R19 R19 was observed up in a wheelchair, to eat in the dining area and sit within the social services offices on and off during the survey. A review for the record for R19 revealed R19 was admitted into the facility on [DATE]. Diagnoses included Alzheimer's, Dementia, Depression, Anxiety and Psychotic Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition with a 3/15 Brief Interview for Mental Status score. Review of the medication orders documented an active order dated 12/13/22 at 5:45 AM for Ativan 0.5 milligrams (mg), Give one tablet by mouth every six hours 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 upon observation, interview and record review, the facility failed to consistently provide evening snacks for three (R5, R34, R76) of four residents reviewed as well as seven anonymous group residents, resulting in resident dissatisfaction with snack/food service. Findings include: R5 On 07/10/23 at 11:26 AM, R5 reported that they are not offered an evening snack very often. Review of the facility record for R5 revealed an admission date of 07/29/22 with diagnoses that included Multiple Sclerosis, Muscle Atrophy and Wasting and Breast Cancer. The Minimum Data Set (MDS) assessment dated [DATE] indicated R5 required total assistance for transfers. The Brief Interview for Mental Status (BIMS) assessment score of 15/15 indicated intact cognition. On 07/11/23 at 11:12 AM, R5 reported they were not offered a snack the previous evening. On 07/12/23 at 09:10 AM, R5 reported that they had not been offered a snack the previous evening. R34 Review of the facility record for R34 revealed an admission date of 10/06/20…

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 prevent a fall during a transfer (by not properly applying a sling) for one sampled resident (R58) of one resident reviewed for accidents resulting in, the resident falling out of their sling during a transfer and onto the floor. Findings include: On 7/10/23 at 10:46 AM, R58 was observed in bed. They were asked about their stay in the facility, and explained that they had a fall a few months ago during a transfer. R58 explained that they were being transferred from their wheelchair to their bed, and that the sling was not all the way underneath their buttocks. R58 explained that as they were being pulled up, the sling slid from underneath them causing them to fall onto the floor. R58 denied pain, but admits that they hit their head on the side of the bed, and that they had a cut to their lip. Review of R58's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Heart Failure, Kidney…

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 observation, interview and record review the facility failed to ensure a medication cart was locked when unattended, expired medications were discarded, and biologicals were dated properly when opened for two of four medications carts and in two of three medication rooms reviewed, resulting in the potential for unauthorized access to items in the medication cart and decreased efficacy of biologicals and medication. Findings include: On 07/11/23 at 8:58 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN) D. LPN D was in a resident's room and the medication cart was unlocked. A staff member walked by and locked the cart. LPN D returned to the cart and attempted to open the drawer without the key. LPN D was then observed to prepare medications for a resident. When LPN D completed preparation of the resident's medication they left the cart and entered the resident's room. The medication cart was left unlocked. When LPN D returned to the cart, they acknowledged they had left it unlocked. On 07/11/23 at 1:00 PM, a review of the 300 low…

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.