Fountain Bleu Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Fountain Bleu Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 6, 2021

  This citation pertains to Intake MI 683 Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility, for one sampled resident (R901) who is severely cognitively impaired, and has diagnoses of Dementia and Muscle Weakness. R901 eloped from the facility on 12/19/2020 at approximately 5:20PM without staff being aware. The resident left their assigned unit, entered into the activities room, and exited through an alarmed door that was not heard by staff. The resident was located approximately 15-45 minutes later by police in an adjacent neighborhood from the facility after being dispatched from a concerned citizen's 911 call. The resident was found wearing a thin sweater, pants and shoes. […]

• Actual harm, isolatedF689Dec 3, 2025

  This citation pertains to Intake Number: 2626257 Based on interview and record review, the facility failed to ensure the safety of one sampled resident (R701) of two residents reviewed for falls resulting in hospitalization. Findings include:Review of the R701's electronic medical record (EMR) revealed that R701 was admitted to facility on 8/25/25 with diagnoses including cerebral infarction, hypertension and dysphagia. A review of the most recent Minimum Data Set assessment (MDS) dated [DATE] indicated R701 required maximum assistance with all activities of living. Further review of R701's care plan indicated that two-person assistance was needed with bed mobility. […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure safety during a transfer for one sampled resident (R26) of six reviewed for accidents, resulting in a laceration to the head and emergency transfer to the hospital. Findings include: R26 On 8/13/24 at 10:06 AM, R26 was asked about the care at the facility. R26 stated, I had a really bad fall, the sling broke. R26 explained they had a fall during a transfer using the sit to stand lift. R26 was asked if they were hurt during that fall. R26 explained, they had a head injury. R26 was asked how many staff were with her to help with the transfer. R26 stated, It may have been one person. […]

• Actual harm, isolatedF684Jul 12, 2023

  This citation has two deficient practices. Deficient practice number one: This citation pertains to Intake number MI00135555. Based on interview and record review the facility failed to ensure timely treatments for a skin condition were initiated and documented on for one (R187) of three residents whose care and treatments were reviewed, resulting in a delay in treatment, and worsening of the skin condition prior to treatment initiation. Findings include: Review of an Intake reported concerns with medication and treatments not received timely and the amount of medication supplied for the rash was insufficient to cover all areas. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2023

  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. […]