Fountain Manor Health & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 24, 2021

  Based on records reviewed and interviews the facility failed to ensure adequate supervision for one resident (Resident #1) reviewed for elopement out of five sampled residents. Resident #1, a vulnerable adult, a smoker that required supervision, used a wheelchair, incontinent of bowel and bladder and required extensive assistance with Activities of Daily Living (ADL) eloped after being dropped off by facility's transportation and staff unsupervised to receive his first [CONDITION(S)] at a local hospital's oncology department 10 miles away from the nursing home. After his first [CONDITION(S)] treatment Resident #1 eloped and his whereabouts remain unknown. Resident #1's health, safety, and life remained at risk. […]

• No harm, potential for more than minimal, patternF690Feb 10, 2025

  Based on observations, record review and interviews the facility failed to provide catheter care according to professional standards for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care as evidenced by two observations of incorrect indwelling urinary catheter care being provided. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2 's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. Staff D,CNA drained the catheter bag and cleansed the tip of the catheter bag with [Germicidal Disinfectant Wipes]. […]

• No harm, potential for more than minimal, patternF880Feb 10, 2025

  Based on observations, record review and interviews the facility failed to reduce the risk of Urinary Tract Infections for two (Residents #2 and Resident #3) out of two residents sampled for indwelling urinary catheter care, as evidenced by staffs' failure to implement infection prevention and control precautions during perineal care for Resident #2 and Resident #3 with indwelling urinary catheter. The findings included: On 02/10/25 at 11:09 AM, during observation of Resident #2's indwelling urinary catheter care performed by Staff D, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN), it was noted that Staff C, RN did not perform handwashing before the procedure started. […]

• No harm, potential for more than minimal, patternF609May 12, 2021

  Based on interviews, and record review, the facility failed to report the immediate report within two hours that lead to a negative outcome for four (Resident #2, #3, #5 and #6) out of four sampled residents. As evidenced by, those residents had a fracture due to falls and the facility reported as Adverse incident report four to fifteen days after the incidents occurred. The facility deficiency has the capacity to affect 136 residents living in the facility at the time of survey. […]

• No harm, potential for more than minimal, isolatedF695May 21, 2026

  Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for three Residents (Resident #19, Resident # 28, and Resident #98) out of 16 residents receiving oxygen therapy. As evidenced by the Residents' oxygen concentrators were not delivering the oxygen at the prescribed flow rate. There were 134 residents residing in the facility at the time of the survey. The findings included.Resident #19During an observation on 05/18/2026 at 8:04 AM Resident #19 was in bed awake, oxygen (02) running at 1.5 liters Per Minute (LPM) via nasal Canula (NC), no distress noted.Observations on 05/19/2026 at 9:09 AM Resident#19 was observed sitting up in bed and on 05/20/2026 at 7:27 AM Resident # 19 was in bed with eyes closed and 02 via NC… […]