Fountainview Ctr For Alzheimer

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident 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 Resident 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 Resident 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 Resident R1. The CNA stated Resident 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 Resident R1 engaged in inappropriate sexual behaviors almost daily and multiple times a day.

CNA1 also stated the only thing that could have prevented Resident 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 Resident R1 and Resident R3 in Resident R1's room. The LPN stated the CNA told her to go look in Resident R1's room. LPN1 stated when she walked into the room, Resident R3 was standing up beside Resident R1's bed with his pants and brief off, and his penis was fully erect. The LPN stated Resident 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 Resident R1, Resident R3 was using his finger to digitally penetrate Resident 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 Resident 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 Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fountainview Ctr for Alzheimer

2631 North Druid Hills Road N E Atlanta, GA 30329

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)

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 Resident R1, Resident R2, and Resident 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 Resident R1 was penetrated digitally, the Administrator stated he only determined Resident R3 was touching Resident R1 in the pubic area. When asked during his investigation, if he was able to determine how LPN1 discovered Resident R1 and Resident 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 Resident R1 and Resident 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fountainview Ctr for Alzheimer

2631 North Druid Hills Road N E Atlanta, GA 30329

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)

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.