Fountain View Rehabilitation and Nursing LLC

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Smoke Deficiencies

Have properly sized and located compartments to protect residents from smoke.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 101 and NFPA 70. This was evidenced by:1. Damaged Outlet in room 34 Life Safety Code Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.NFPA 70 Section 406.5 Receptacle Mounting. Receptacles shall be mounted in boxes or assemblies designed for the purpose, and such boxes or assemblies shall be securely fastened in place unless otherwise permitted elsewhere in this Code.NFPA 70 Section 406.5 (F) Exposed Terminals. Receptacles shall be enclosed so that live wirin.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.1.Elevator Room Large amounts of hydraulic fluid need to be collected from inside the catch basinWall repairs need to be conducted. The rated room has multiple "California Patches"8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administra.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress door by Room 35 not releasing under fire alarm | Door was diable during surveyNFPA 101 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(1)The door leaves shall unlo.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.Assessment of closets sprinkler coverage (Sprinkler head is located in the middle over sink inside the enclosure each closet does not have its own sprinkler head)2.Antifreeze needs to be replaced/The company should verify that new viscosity will not affect system performance (ensure this is documented)NFPA 25 5.3.4.4.1* For systems installed prior to September 30, 2012, listed antifreeze solutions shall not be required until September 30, 2022, where one of the following conditions is met:(1)*The concentration of the antifreeze solution shall be limited to 30 percent propylene .. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility' s general characteristics. The facility is a one-story Type V protected wood frame structure, approximately 51,644 sq. ft. The basement is no longer used by the residents and is used by support services. The basement has an exterior exit to grade level. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility was licensed for 90 beds and operated as a non-secured facility at the time of this survey. The census was reported to be 84 residents total. The survey ..