Fountain Care at Sunset Hills

In the surveyor’s words

From the most serious findings on record at Fountain Care at Sunset Hills, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 20, 2021

  Based on observation, interview and record review, the facility failed to maintain safe water temperatures, between 105 degrees Fahrenheit (F) and 120 degrees F, for the residents at the facility. The facility replaced their boiler on 1/6/21 and failed to monitor water temperatures to ensure they were within safe limits. At the time the boiler was changed, the facility did not employ a maintenance supervisor to oversee the maintenance department. In addition, the facility had not routinely measured water temperatures to ensure they were within safe and comfortable limits since 7/7/20. Five cognitively impaired residents were identified, who were physically able to gain access to the bathroom sink and/or shower rooms (Residents #600, #604, #601, #602 and #603). […]

• Immediate jeopardy, isolatedF684Jan 17, 2025

  See deficiency cited at Event ID #172413 Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). […]

• Immediate jeopardy, isolatedF684Oct 21, 2024

  Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). […]

• Immediate jeopardy, isolatedF684Oct 21, 2024

  Based on interview and record review, staff failed to implement a system to ensure facility staff communicated a report on residents' conditions to agency staff prior to their shifts and failed to direct agency staff where to find the binder containing instructions on residents' care needs. The facility failed to ensure one resident's (Resident #18) care plan instructions for staff reflected the resident's assessed needs, including use of mechanical lift for transfers. On 12/17/24 around 12:00 P.M., an unknown nurse directed Certified Nurse Aide (CNA) C to transfer the resident from his/her bed without communication of the resident's need for mechanical lift transfer. CNA C utilized a gait belt, instead of using a Hoyer lift (mechanical lift). […]

• Immediate jeopardy, isolatedF689Dec 22, 2023

  Based on interview and record review, the facility failed to ensure one resident (Resident #104) with a diagnosis of dysphagia (difficulty swallowing) was served food in the proper consistency to prevent choking. Staff reported the resident was routinely served a whole, hardboiled egg for breakfast. On [DATE], the resident was found unresponsive in the first-floor dining room. Cardio Pulmonary Resuscitation (CPR, a lifesaving technique used when breathing or heartbeat has stopped) was started and a piece of hard boiled egg, approximately 2 inches in diameter, was removed from the resident's mouth. The resident expired at the facility. The census was 97. The Administrator was notified on [DATE] at 4:00 P. M., of an Immediate Jeopardy (IJ) past noncompliance which began on [DATE]. […]