Fountainbleau Lodge

In the surveyor’s words

From the most serious findings on record at Fountainbleau Lodge, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 18, 2024

  Based on observation, record review, and interview, the facility failed to provide protective oversight for one (Resident #1) of four sampled residents, when facility staff left the facility's medication overflow cart unlocked and unattended. Resident #1 gained access to the cart and took two medication cards of gabapentin (a medication used to treat seizures disorder and used for nerve pain) and one card of Metoprolol (a medication used to treat high blood pressure) to his/her room. He/She reported taking 6 pills of Gabapentin and 6 pills of Gabapentin were missing which placed the resident in danger of potential overdose. The facility census was 27. The administrator was notified on 06/11/24 at 10:30 A.M. of an Immediate Jeopardy (IJ) past non-compliance which began on 06/09/24. […]

• Immediate jeopardy, isolatedF678Jun 30, 2022

  Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a procedure to support and maintain breathing and circulation for a person who has stopped breathing and/or whose heart has stopped) for one resident (Resident #1) of 19 residents identified as having a full code status (CPR required in the event of cardiac or respiratory arrest). Staff found the resident unresponsive on [DATE] and failed to initiate CPR and call 911. The resident died in the facility. The facility census was 29. On [DATE] at 4:20 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE] the facility Director of Nursing (DON) was notified of the incident and an investigation was started. […]

• No harm, potential for more than minimal, widespreadF804Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice had the potential to affect all residents in the facility. The facility's census was 30.Review of the facility's policy titled, Food Preparation and Service, revised November 2022, showed:- Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices;- Danger zone means temperatures above 41 degrees Fahrenheit ( F) and below 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness;- Did not address holding/serving temperatures of food. […]

• No harm, potential for more than minimal, widespreadF812Aug 8, 2024

  Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross contamination and food-borne illnesses. This deficient practice had the potential to affect all residents. The facility's census was 29. Review of the facility's policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised November 2022, showed: - Food and nutrition service employees follow appropriate hand hygiene and sanitary procedures to prevent the spread of food borne illnesses; - All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing food-borne illnesses; - Employees must wash their hands whenever entering or re-entering the kitchen; - Before… […]

• No harm, potential for more than minimal, widespreadF867Mar 10, 2023

  Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 30. Record review of the facility's QAPI Plan, effective 7/19/17, showed: - The QA&A Committee reports to the executive leadership and governing body and is responsible for meeting, at a minimum, on a quarterly basis, more frequently if necessary; coordinating and evaluating QAPI program activities; developing and implementing appropriate plans of action to correct identified quality deficiencies; regularly reviewing and analyzing data collected under the… […]