Health inspection·June 18, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, reviews and interviews, the facility's staff failed to notify one (Resident #1) out of three sampled resident's family /representative of a change in condition; as evidenced by Resident #1 had a fall and a progress note written the day of the incident, indicated no next of kin was listed to be notified. The findings included: On 6/16/25 at 1:15 PM Resident#1 was observed seated in the dining area amongst other residents. Resident#1 did not respond when greeted by surveyor. On 6/17/25 at 10:35 AM Resident#1 was observed seated in wheelchair on the patio with staff supervising. Resident #1 stated: Sometimes I have racing thoughts, and I have to calm myself down . Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: abnormalities of gait and mobility, lack of coordination and seizures. Record review of a Quarterly Minimum Data Set (MDS) reference dated 5/14/25 indicated Resident #1 is severely impaired cognitively and had no falls since reentry or the prior assessment. Record review of a Care Plan start date 1/24/23 and last reviewed/revised on 5/15/25 revealed Resident #1 was at high risk for fall and injuries secondary to diagnosis that included: Impaired gait, Seizure disorder, Impaired cognition, fall incident occurred 1/24/23. No injury noted with interventions that included: remind resident not to try to get out of bed by him/herself to use call light and request assistance, maintain walkway free from clutter and encourage resident to use call bell and request assistance as needed . Record review of a progress note dated 1/24/23 at 3:00 AM revealed Resident #1 was found on the floor, the Medical Doctor was notified, and next of kin/responsible party not assigned. Record review of a Fall Event Report dated 1/26/23 for Resident #1 section: Notifications revealed Name of Responsible Party: none assigned. On 6/17/25 at 2:45 PM The admission Coordinator stated: Prior to admission, the demographic sheet is created with the proxy/emergency contact in case there is an incident where the family needs to be notified. (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 06/18/2025 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)