Health inspection·November 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safety of a vulnerable Resident (Resident #32) out of 29 sampled residents. As evidenced by disposable shaving razors were observed at the resident's bedside. There were 133 residents residing in the facility at the time of the survey. The findings Included: On 11 /12/24 at 09:05 AM and on 11/12/24 at 01:00 PM shaving razors observed on Resident #32's bedside table. On 11/14/24 at 09:10 AM three (3) shaving razors were observed on the resident's bedside table. Review of Resident #32's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Paranoid schizophrenia and Bipolar disorder. Review of the Physician's Orders Sheet for November 2024 revealed Resident #32 had orders that included daily medications for Schizophrenia and a medication three times a day for Anxiety. Review of Resident # 32's Schedule 5 Day Minimum Data Set (MDS) dated [DATE] indicated in Section C for Cognitive Patterns a Brief Interview for Mental status Score of 15 out of 15 indicating the resident is cognitively intact. Section GG for Functional Status documented Partial moderate assistance for activities of daily living. Record review of Resident # 32's Care Plans Reference date 07/04/2024 revealed: Resident is noted with self-care deficit, resident needs assistance with his activities of daily living (ADL) due to a Diagnosis of Altered Mental Status, Parkinson's Disease, Chronic Diarrhea, Schizophrenia, Bipolar Disease, Insomnia, Anxiety, and Cancer of Skin. Interventions include-Obtain all equipment necessary for ADL care and place items close to resident, assist with dressing, grooming, and hygiene needs daily to keep resident clean and neat During an interview on 11/14/24 at 09:42 AM Certified Nursing assistant (CNAs) (Staff A) revealed; the resident requires supervision for his ADLs, he loves to shave himself and he is supervised when he is shaving, the resident always get razors from somewhere and takes it to his room every time; whenever she sees razors in his room she takes it away and store it properly in the storage area. Staff A went to the resident's room during the interview with the surveyor and removed the 3 razors on Resident #32's bedside table. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105172 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105172 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Manor Health & Rehabilitation Center 390 NE 135th St North Miami, FL 33161 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)