Inspection Reports for Fountain Springs Healthcare Center

The inspection was conducted based on complaints and facility-reported incidents involving failure to complete a baseline care plan within 48 hours for a recently admitted resident, failure to ensure a resident's Wander Guard was not removed or documented properly, and failure to secure a resident's wheelchair during transport.

The facility failed to complete a baseline care plan within 48 hours for one resident, failed to ensure proper use and documentation of a Wander Guard for another resident, and failed to secure a resident's wheelchair during transport, resulting in potential harm. Corrective actions and education were implemented and confirmed by the survey.

The visit was complaint-related based on facility-reported incidents involving resident 38's baseline care plan delay, resident 77's Wander Guard removal and documentation issues, and resident 60's wheelchair transport incident. The complaints were substantiated with findings of non-compliance.

The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, advance directives, resident assessments, PASARR screening, respiratory care, medication administration, and pharmaceutical services.

The facility failed to ensure residents were properly assessed and authorized for self-administration of medications, accurate documentation of advance directives, accurate resident assessments, timely PASARR rescreening, proper infection control practices for respiratory equipment, correct medication administration and documentation practices, and proper pharmaceutical services including controlled substance accountability.

The inspection was conducted due to a complaint investigation regarding allegations of abuse by a certified nurse aide (CNA) towards a resident, which were not promptly investigated or reported by the facility.

The provider failed to promptly investigate and report allegations of verbal abuse by CNA G towards resident 1, which was confirmed after an investigation. Corrective actions including disciplinary measures, education, and audits were implemented following the incident.

The complaint investigation was triggered by allegations from resident 1 that CNA G used inappropriate language, gestures, and took pictures and recordings of the resident without consent. The facility initially failed to investigate or report the incident. The allegations were later validated, resulting in CNA G's termination. The complaint is substantiated.

The inspection was conducted due to a facility reported incident (FRI) involving a resident choking during a meal service on 7/24/24, which resulted in the resident's death. The investigation focused on the provider's failure to follow a physician-ordered diet and to initiate timely emergency medical intervention.

The provider failed to ensure a physician-ordered diet was followed and appropriate emergency medical intervention was initiated timely for one sampled resident who choked and subsequently died. The facility implemented a plan of correction including staff education, retraining, audits, and personnel changes, which was confirmed to have removed the immediate jeopardy by 8/15/24.

The complaint investigation was substantiated. The resident choked on improperly prepared food on 7/24/24, emergency interventions were delayed or improperly performed, and the resident died at the facility. The facility had past non-compliance related to these issues and implemented corrective actions.

The inspection was conducted to review a facility reported incident (FRI) involving a mechanical lift accident on 4/29/24 and to verify the provider's corrective actions.

The report confirmed past non-compliance due to a certified nursing assistant not following mechanical lift instructions, resulting in a resident fall without injury. The facility implemented systemic changes including staff education, device evaluation, and competency audits to prevent recurrence.

The inspection was conducted to assess compliance with infection prevention and control practices, including catheter care, wound dressing changes, and PICC line dressing procedures.

The facility failed to ensure proper infection control practices were followed by licensed practical nurse and certified nursing aides during catheter care and dressing changes. Observations revealed inadequate hand hygiene, improper use of gloves, failure to use barriers, and improper handling of sterile supplies, posing minimal harm or potential for actual harm to a few residents.

The inspection was conducted due to a complaint investigation following an incident where a resident with a history of wandering and severe cognitive impairment eloped from the facility on 12/25/23.

The provider failed to maintain a secured environment for the resident, as the door alarm battery was depleted, door alarm checks were not performed on weekends or holidays, and the alarm speaker volume was turned down. Corrective actions were implemented on 12/26/23, including assigning responsibility for door alarm testing and resetting the alarm system volume, with monitoring to prevent recurrence.

The complaint investigation was substantiated as the resident eloped on 12/25/23 due to failure of the door alarm system and inadequate supervision. The provider recognized the deficiency and implemented corrective actions on 12/26/23.

The inspection was conducted to assess compliance with privacy, infection control, medication administration, procedural standards, and overall quality of care at Fountain Springs Healthcare.

The facility failed to maintain resident privacy due to window blinds issues, did not secure resident medical records and medication carts properly, and staff did not consistently follow infection control protocols including hand hygiene, gown use, and cleaning of equipment. Procedural errors were noted in IV catheter removal and inhaler medication administration.