Inspection Reports for
Fountains Rehabilitation at Mill Cove

Across 37 visits, 19 deficiencies were recorded, all Class 3 or 4, with no serious deficiencies. Three legal actions with fines totaling $2,000 were taken.

The complaint investigation revealed that Resident #29 was not re-evaluated with a Level 2 PASRR despite indications from a Level 1 PASRR that such evaluation was required. Additionally, Resident #25 did not receive timely nail care as required by their care plan, despite being on antiplatelet therapy which increases risk.

The facility failed to ensure that a resident with a serious mental illness received the required Level 2 PASRR evaluation and failed to provide timely nail care and grooming to another resident as outlined in their care plans. Observations, interviews, and record reviews confirmed these deficiencies affecting a few residents.

The complaint investigation was substantiated with findings of disrespectful treatment of residents, medication administration errors, failure to administer tube feedings as ordered, incorrect oxygen flow rates, and a medication error rate of 13.33%.

The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to administer medications and tube feedings as ordered, failure to provide oxygen at the prescribed flow rate, and a medication error rate exceeding 5%. Several residents experienced inadequate care related to incontinence, medication administration, enteral feeding, and respiratory therapy.

The facility failed to ensure staff knocked and announced themselves prior to entering resident rooms and failed to provide privacy to residents during personal care for two residents (#609 and #610). Observations included uncovered residents, open doors, illuminated call lights, and staff entering rooms without knocking or identifying themselves. Interviews with staff confirmed expectations for privacy and dignity were not consistently met.