Fountains, The

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. 2. The Registered Dietitian (RD) did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 4. […]

• No harm, potential for more than minimal, widespreadF802Apr 20, 2023

  Based on observation, interview, and record review the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: 1. There was no evidence training occurred for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. 2. Staff did not perform hand hygiene or change gloves between tasks. 3. Staff did not adequately restrain hair or facial hair. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries. 5. Equipment was not cleaned according to professional standards of practice. 6. […]

• No harm, potential for more than minimal, widespreadF812Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. Eleven of 11 kitchen staff did not perform hand hygiene and glove use according to professional standards of practice which increased the likelihood of cross contamination. 2. Two of three hand washing areas used by kitchen staff had the potential to contaminate hands during the hand washing procedure when one sink area had drying towels that were contaminated due to dispensing onto the soiled sink and the second sink areas faucet dispensed water close to the sides of the sink which caused hands to touch the sides of the sink during the hand washing process. 3. […]

• No harm, potential for more than minimal, patternF641Mar 20, 2025

  Based on observation, interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #47) of 2 residents reviewed for Preadmission Screening and Record Review (PASRR) requirements and 1 (Resident #16) of 3 residents reviewed for dental concerns. Findings included: 1. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, revealed, A1500: Preadmission Screening and Resident Review (PASRR) included Steps for Assessment, which included, 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. […]

• No harm, potential for more than minimal, patternF755Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when a used Emergency Kit (E-Kit, a storage box that houses an emergency supply of medications) was not removed and replaced according to facility policy. This failure had the potential for an E-Kit to have an insufficient amount of an emergency supply of medication available for the facility's residents. Findings: During an observation on 4/18/2023 at 1:34 PM, the E-Kit at nurse's station two of the facility had an E-Kit opened on 4/13/2023 at 12:53 PM, for a ipratropium bromide and albuterol sulfate inhalation solution (a combination medication for helping with shortness of breath), 0.5mg/3mg (milligram, unit of measure for weight), and again opened on 4/18/2023 at… […]