Avamere at Three Fountains

In the surveyor’s words

From the most serious findings on record at Avamere at Three Fountains, in the surveyor’s own words.

• Actual harm, isolatedF658Apr 1, 2024

  Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional standards for 1 of 7 sampled residents (#101) reviewed for significant medication error. As a result, Resident 101 experienced a decline in condition and required hospitalization for a drug overdose. Findings include: On 8/30/23 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined Staff 6 failed to adhere to professional standards of practice for medication administration. […]

• Actual harm, isolatedF760Apr 1, 2024

  Based on interview and record review it was determined the facility failed to ensure the resident was free from a significant medication error for 1 of 3 sampled residents (#101) reviewed for medications. As a result, Resident 101 was hospitalized for a drug overdose. Findings include: On 8/30/23 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined significant medication errors were found. An interview on 3/28/24, with Staff 1 (Administrator) and Staff 2 (DNS) revealed the facility's plan of correction included the following: -Staff education completed for all CMAs and LPNs on Administering Medications Policy, 7 Rights of Medication Administration, 5 Ways to Identify Residents and medication pass audit. […]

• Actual harm, isolatedF689Sep 10, 2021

  Based on observation, interview and record review it was determined the facility failed to ensure staff followed the care plan related to fall safety for 2 of 3 sampled residents (#s 3 and 11) reviewed for accidents. Resident 3 fell out of bed and sustained a right [CONDITION(S)]. Findings include: 1a. Resident 3 admitted to the facility in 2020 with diagnoses including dementia and a stroke. A comprehensive care plan dated 8/18/20 and revised on 3/4/21 indicated Resident 3 was a high fall risk related to a history of falls. Staff were directed to check on Resident 3 frequently when she/he was in bed and the bed was to be in a lowered position with fall mats on each side of the bed. […]

• No harm, potential for more than minimal, widespreadF880Jan 16, 2025

  Based on observation, interview, and record review it was determined the facility failed to ensure transmission-based precautions were followed, surfaces were sanitized and linen was properly transported for 3 of 5 halls reviewed for infection control precautions. This placed residents and staff at risk for cross-contamination. Findings include: The 12/29/21 facility Categories of Transmission-Based Precautions instructed staff: -to wear an isolation gown that was securely tied around the staff's neck and back when entering a COVID-19 positive room on special droplet precautions. -to use dedicated, non-critical resident equipment (stethoscopes) when possible to prevent cross-contamination. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2023

  Based on interview and record review it was determined the facility failed to ensure sanitation protocols were followed for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses. Findings include: The 8/2023 High Temperature Dish Machine Log revealed from 8/4/23 through 8/21/23 during breakfast all final rinse water temperatures were below 180 degrees. The lunch period dish machine temperatures revealed only on 8/10/23, 8/16/23 and 8/21/23 were the required 180 degree final rinse water temperature for sanitation achieved. […]