Fountainview CTR for Alzheimer

In the surveyor’s words

From the most serious findings on record at Fountainview CTR for Alzheimer, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 17, 2025

  Based on interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure residents were free from sexual abuse for three of six residents reviewed for abuse (Resident (R) 2, R3, and R6). Specifically, R1 displayed inappropriate sexual behaviors towards others on 6/20/2025 when she grabbed a male housekeeper's private area (groin) and buttocks. The resident's inappropriate sexual behavior towards staff members progressed to resident's on the South Pavillion unit sustaining sexual abuse. Even though the facility was aware of R1's inappropriate sexual behavior and her abuse of other residents, the facility failed to implement any interventions to protect the residents who resided on the unit. […]

• Immediate jeopardy, isolatedF610Aug 17, 2025

  Based on interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to complete a thorough investigation which included interviewing and/or assessing other residents who resided on the South Pavillion unit and interviewing staff who worked on the unit for two of two abuse investigations involving residents (Resident (R) 1, R2, and R3). Also, during the facility's investigation, the Administrator who was the Abuse Coordinator failed to thoroughly investigate and identify Certified Nurse Aide (CNA) 2's failure to protect R3 when she discovered R3 in R1's room with his pants off; instead of intervening, the CNA left the resident's room and reported her observations to the nurse. […]

• Immediate jeopardy, isolatedF657Aug 17, 2025

  Based on interview, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to revise the resident's care plan with nonpharmacological interventions for inappropriate sexual behavior for one of nine sampled residents (Resident (R) 1). This failure led to multiple residents on the South Pavillion unit being victims of sexual abuse by R1. Cross Reference: F600 Free from Abuse and Neglect.The facility's failure to ensure R1's care plan was revised with interventions protecting residents from sexual abuse had caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy was identified on 8/15/2025 and was determined to exist on 6/20/2025. […]

• Actual harm, isolatedF686Jan 18, 2024

  28604 Based on observations, interviews, record review, and review of the policy titled Pressure Injury Prevention and Management, the facility failed to implement pressure injury interventions to prevent the development of unstageable pressure ulcers for two of five sampled residents (R) (R37 and R98) reviewed for pressure ulcers; failed to conduct weekly skin assessments of R98's left hip DTI (deep tissue injury) and document treatments to R98's left hip for 10 days. Harm was identified to occur on 9/6/2023 for R37 when an unstageable DTI developed on the right heel, and then increased to a Stage 3 pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2024

  Based on observations, interviews, manufacturer instruction review, and review of facility policies, the facility failed to discard containers of buttermilk with expired manufacturer's expiration dates, failed to date nutritional supplements when removed from freezer storage and when opened, and failed to clean drawers that contained food products. These failures had the potential to affect all 114 residents who resided in the facility. Findings included: Review of the policy titled, Storage, dated [DATE], indicated Refrigerated Storage 1. Store perishable food in refrigerator and/or foods marked 'Keep Refrigerated' by the manufacturer . 3. […]