Fountain Inn Post Acute

Based on observation, interview, record review, and facility policy review, the facility failed to store respiratory equipment appropriately for 2 (Resident (R)5 and R66) of 3 sampled residents reviewed for respiratory care.Findings included: An undated facility policy titled, Storage of Respiratory Equipment, indicated, All respiratory equipment shall be stored in a manner that maintains cleanliness, prevents contamination, ensures readiness for use, and complies with infection prevention and life safety standards. Procedures 1. General Storage Requirements * Respiratory equipment must be stored: * In a clean, dry * Off the floor and away from sinks, toilets, and splash zones * Protected from dust, moisture, and temperature extremes * Storage areas must be clearly labeled and routinely inspected. 1. An admission Record indicated the facility admitted R66 on 12/13/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, mixed simple, and mucopurulent chronic…

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, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan to maintain the resident's highest physical well-being for 1 (Resident (R)29) of 3 sampled residents reviewed for falls.Findings included:A facility policy titled, Falls - Clinical Protocol, revised 03/2018, revealed, 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The policy specified, 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.An admission Record revealed the facility admitted R29 on 04/15/2025. According to the admission Record, the resident had a medical history that included…

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, record review, and facility policy review, the facility failed to provide care and services necessary to maintain or improve the highest practicable physical well-being of a resident receiving dialysis by not following physician-ordered fluid restrictions for 1 (Resident (R)70) of 1 sampled resident reviewed for dialysis.Findings included:A facility policy titled, Encouraging and Restricting Fluids, revised 10/2010, indicated, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy specified, 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake.An admission Record indicated the facility admitted R70 on 10/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease, hypotension of hemodialysis, and dependence on renal dialysis.A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2025, revealed R70 had a Brief Interview for Mental Status…

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 facility policy review, the facility failed to ensure appropriate storage and disposal of drugs and biologicals during observation of medication administration with 1 (Resident (R)74) of 5 residents observed for medication administration.Findings included:A facility policy titled, Storage and Expiration Dating of Medications and Biologicals, revised 06/30/2025, revealed, 5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.A facility policy titled, Disposal of Medications, revised 08/26/2025, revealed, 13.2 Wasted single doses of medications for disposal should [be] disposed of in a manner that limits access to them by unauthorized personnel or residents.During medication administration observation on 12/17/2025 at 9:24 AM, Licensed Vocational Nurse (LVN)2 prepared medication to be administered to R74. LVN2 dropped one multivitamin with minerals capsule and placed the capsule into the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation and interview, the facility failed to ensure medications were free of expiration and properly labled for 2 of 3 medication carts and 1 of 1 treatment carts. Findings include: Review of the facility policy dated 2001, titled, Medication Labeling and Storage, revealed under the policy, If the facility has discontinued , outdated or deteriorated medications or biologicals, the dispending pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biolagicals dispensed by the pharmacy is consistant with applicable federal and state requirements and currently accepted pharmceutical practices. The medication label includes, at a minimum: medication name, prescribed dose, strength, expiration date, when applicable, residents name, route of administration and appropriate instructions and precautions. An observation of the treatment cart on [DATE] at 9:41 AM revealed the following: Nystation cream for Resident (R) 47…

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 facility policy the facility failed to offer/provide Activities of Daily Living (ADL) care to Resident (R)12 and R27. 2 of 3 reviewed for ADL care. Findings include: Review of facility policy titled, ADLs Supporting revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Policy interpretation and implementation include residents will be provided with care, treatment, and services to ensure that ADL do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation, record review and interview, the facility failed to ensure the medication error rate was 5% or less. The medication error rate was 7.69%. Findings include: Review of the facility policy, dated 2001 and titled, Administering Medications records under the policy, Medications are administered in accordance with prescriber orders, including any required time frame. An observation was conducted on 09/23/24 at 9:17 AM of Licensed Practical Nurse (LPN)1 during medication administration for Resident (R)4. During medication administration LPN1 stated, There are 2 medications that I do not have available to give him right now. I will make the Unit Manager (UM) and Nurse Practitioner (NP) aware. The medications that were not available included Floraster oral capsules and Donepezil 10 milligrams (mg). Record review for R4 revealed he was admitted to the facility on [DATE] with diagnoses to include the following; acute respiratory failure with hypoxia, Type 2 diabetes,…

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, record review, and review of the facility policy, the facility failed to accurately submit the Payroll Based Journal (PBJ) for Quarter Three (April 1st - June 1st), 2024 to reflect Registered Nurse (RN) hours. 15 of 19 days reviewed for RN coverage. Findings include: Review of facility policy titled, Reporting Direct Care Staffing Information (PBJ) last revised August 2022, revealed Direct care staffing is reported electronically to CMS through the PBJ System. Policy Interpretation and Implementation include complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS. Direct care staff are those who, through interpersonal contact with residents or resident care management provide care and services to allow residents to attain or maintain their highest practicable physical, mental, and psychosocial well being. Record review prior to the entrance of the survey of the PBJ Staffing Data Report for Quarter 3 (April 2024 - June 2024) revealed the following dates with missing RN…

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, facility policy, and federal regulation the facility failed to provide documentation that the Medical Director (MD) attended the quarterly Quality Assurance and Performance Improvement (QAPI) Program. 1 of 2 Quarters reviewed. Findings include: Review of facility policy titled, QAPI Program revealed This facility shall develop, implement and maintain an ongoing, facility wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy interpretation and implementation include the Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state and local regulatory agency requirements. A phone interview on 09/25/24 at 12:45 PM with the Administrator revealed that have recently been hired at the facility, during interview the Administrator revealed he was unable to find sign in sheets to verify that the previous Medical Director (MD) attended the quarterly QAPI meetings. An interview on 09/25/24 at 1:39 PM with the current MD for the facility revealed that they…

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 review of the facility policy, observation, and interviews, the facility failed to follow proper infection control practices to clean the glucometer for 1 of 1 resident (R) reviewed for glucometer cleaning. Findings include: Review of the facility's policy dated 05/25/2019, and titled, Glucometer Cleaning revealed The purpose of this procedure are to provide guidelines for cleaning a glucometer used for blood sugars and to prevent the introduction of bacteria. If residents use individual glcometers, clean prior to use or when visibly soiled. On 09/24/2024 at 8:19 AM, an observation of Registered Nurse (RN)1 performing an accu check revealed the following: RN1 stated, All the glucometers are individual. She then removed the glucometer from the medication cart. She was asked if she cleaned the glucometer, RN1 said, No, it should be clean since it was in the container for the resident. She placed a barrier on an overbed table and placed the glucometer on the barrier. RN1 donned gloves, cleaned the finger with an alcohol prep pad, and pricked it with a lancet. After obtaining…

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 review of facility policy, observations, and interviews, the facility failed to ensure staff performed adequate hand hygiene for three of three survey days. Failure to perform adequate hand hygiene can lead to cross contamination. Findings include: Review of the facility's policy titled, Hand Hygiene Policy and Table, dated 05/20/19, revealed, Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Between resident contacts . [and] after handling contaminated objects . The use of gloves does not replace hand hygiene if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Observation on 07/25/22 at 1:15 PM revealed Certified Nursing Assistant (CNA)3 already in room feeding resident (R) 35 with gloves on. After feeding R35, CNA3 took off her gloves and left R35's room briefly to talk with someone in the hallway. CNA3 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.