Fountainview Ctr For Alzheimer
FOUNTAINVIEW CTR FOR ALZHEIMER in ATLANTA, GA — inspection on August 17, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
resident noted to be fondling resident, both residents were immediate separated and assessed with no acute injuries noted.
During an interview on 8/13/2025 at 3:00 pm, the Administrator stated if there was no contact made by R1 to another resident when she was having inappropriate sexual behaviors, then it was not abuse just the resident's behavior.
During an interview on 8/13/2025 at 3:50 pm, the Director of Education (DOE) stated she was responsible for providing staff abuse training.
When asked about the above documented progress notes, the DOE stated only the incidents on 7/29/2025 and 7/31/2025 met the definition of abuse.
The DOE also stated it was not sexual abuse if the other resident was not physically touched by R1.
During an interview on 8/13/2025 at 4:25 pm, the Registered Nurse Supervisor (RNS) stated in her opinion, if a cognitively impaired resident pulled her top up in front of residents and staff, that was not abuse, but a behavior. If the other resident would have been touched by R1, then it would have been possible abuse.
During an interview on 8/14/2025 at 9:35 am, Certified Nurse Aide (CNA) 1 stated she works on the South Pavillion unit and was familiar with R1.
The CNA stated R1 was very sexual and could be redirected; however, she would then just go to a different resident and do inappropriate sexual behaviors to them. CNA1 stated R1 engaged in inappropriate sexual behaviors almost daily and multiple times a day.
CNA1 also stated the only thing that could have prevented R1 from bothering other residents would have been to place the resident on one-to-one supervision.
The CNA stated sexual abuse was any unwanted sexual behaviors towards another person or resident.
During an interview on 8/14/2025 at 10:38 am, Licensed Practical Nurse (LPN) 1 stated a CNA observed R1 and R3 in R1's room.
The LPN stated the CNA told her to go look in R1's room. LPN1 stated when she walked into the room, R3 was standing up beside R1's bed with his pants and brief off, and his penis was fully erect.
The LPN stated R1 had her shirt pulled behind her head, her breast fully exposed with a blanket covering the rest of the resident's body.
The LPN stated when she pulled the blanket off R1, R3 was using his finger to digitally penetrate R1's vagina.
During an interview on 8/14/2025 at 11:52 am, the Director of Nursing (DON) stated there were no assessments for residents' capacity to consent for sexual contact completed by the facility.
The DON also stated sexual abuse was if a resident received any unwanted sexual behaviors from R1 that involved contact.
When asked if a resident had to touch another resident before he considered it as abuse, the DON stated, Yes.
The DON stated a resident just exposing her breast to another resident even if the resident also stated something verbally during the exposing of her breast, that was a behavior and not sexual abuse.
During an interview on 08/14/25 at 12:18 PM, the Administrator stated R1 was not the normal nursing home resident as her disease manifested the way it did, and she has not filter and that is why she has inappropriate sexual behaviors.
The Administrator stated that without physical contact, he would not consider it abuse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fountainview Ctr for Alzheimer
2631 North Druid Hills Road N E Atlanta, GA 30329
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
time.
During an interview on 8/14/2025 at 12:18 pm, when asked if he interviewed other residents on the unit or if nursing completed any type of skin or body assessments on the other residents of the unit for the reported abuse incidents on 7/29/2025 and 7/31/2025, the Administrator stated he only interviewed R1, R2, and R3.
The Administrator stated he did not interview any of the other residents on the unit because the other residents would not be able to articulate anything useful.
The Administrator also stated there were no assessments of any kind completed on the other residents of the unit by nursing or social services after the incidents because it did not affect any other residents.
Continued interview revealed that the Administrator did not have staff write out any statements and just verbally spoke to the nurses who documented the two incidents; however, he did not document the interview or have the nurses write out any statements.
When asked did his investigation determine that R1 was penetrated digitally, the Administrator stated he only determined R3 was touching R1 in the pubic area.
When asked during his investigation, if he was able to determine how LPN1 discovered R1 and R3's sexual encounter, the Administrator stated he believed the LPN was making rounds and walked in on it.
When asked if he was aware a CNA observed the sexual encounter between R1 and R3 first, did not intervene, and left the residents alone to go report the incident to the nurse, the Administrator stated he was not aware of that.
The Administrator stated it was his expectation CNA2 would have intervened and separated the residents before reporting to the nurse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fountainview Ctr for Alzheimer
2631 North Druid Hills Road N E Atlanta, GA 30329
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited FOUNTAINVIEW CTR FOR ALZHEIMER in ATLANTA, GA for a deficiency under regulatory tag F-F0657 during a complaint investigation conducted on 2025-08-17.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 3 deficiencies cited during this inspection of FOUNTAINVIEW CTR FOR ALZHEIMER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-18.