Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain Bleu Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident requiring maximum assistance for bed mobility and incontinence care, as documented in their care plan and Kardex, was assisted by only one CNA during a bed change. The CNA did not observe the posted assistance requirement and attempted the task alone, resulting in the resident rolling off the bed, sustaining injuries, and requiring hospital evaluation.
Medication storage was deficient in two medication carts when multiple multi-use medications were found without opened dates or with opened dates beyond the allowed timeframe. An LPN observed Latanoprost Ophthalmic Solution, ProSource Plus, and Milk of Magnesia were 30 days past the opened date, while Fluticasone/Salmeterol Diskus, Biofreeze Topical Gel, Nystatin Suspension, and Deep Sea Nasal Spray lacked opened dates. The ICP and DON stated multi-use medications should be dated when opened and discarded after the required period.
Missing EBP Signage for Residents With Wounds: The facility failed to post EBP signs on the doors of two residents who had wounds and ordered wound care. One resident had intact cognition with pressure and venous/arterial ulcers, and the other had impaired cognition with an unstageable pressure ulcer. Both rooms were observed without EBP signage, and the DON confirmed the rooms should have had the signs because the residents had wounds.
A resident with impaired cognition and a history of multiple falls was not provided with a required scoop/perimeter mattress as documented in their care plan. Despite the intervention being ordered to prevent further falls, the resident was repeatedly observed on a regular mattress, and staff confirmed the prescribed device was not in place.
A resident sustained a head laceration during a transfer using a sit-to-stand lift, as only one staff member was present instead of the required two. The resident, who was dependent on assistance for transfers due to limited mobility, fell and hit their head, necessitating emergency hospital care. Interviews with facility staff confirmed the breach of policy, as the facility requires two staff members for such transfers.
A resident with dysphagia and multiple sclerosis was observed using a straw despite a care plan intervention prohibiting its use due to a history of aspiration. The care plan, active since March 2023, specified 'no straws' as confirmed by the SLP. Staff members were observed removing the straw on multiple occasions, indicating a failure to adhere to the care plan.
A resident with Alzheimer's and a history of vascular ulcers was observed without heel protectors and not on an air loss mattress, contrary to their care plan. The DON and an LPN acknowledged the care plan was outdated as the resident's wound had healed, but it had not been revised to reflect the current status.
The facility failed to ensure call lights were accessible for three residents with severely impaired cognition. Observations revealed call lights tied to bed rails, on the floor, or under bed covers, making them unreachable. Despite being capable of using the call lights, residents indicated they would yell for assistance. The DON confirmed the expectation for call lights to be within reach, aligning with facility policy.
The facility failed to implement fall prevention interventions for two residents, leading to deficiencies. One resident, with a history of falls, was found on a regular mattress instead of a perimeter mattress, and their call light was out of reach, resulting in a fall. Another resident's bed was not in the low position due to malfunction, contrary to their care plan. The DON confirmed the oversight and a work order was submitted for the bed issue.
The facility failed to secure medications on three separate medication carts, which were found unlocked and unattended in hallways with resident rooms. An unidentified nurse acknowledged the mistake when questioned about one of the carts. The facility's policy requires medications to be stored in secured, locked locations accessible only to designated staff, which was not followed in these instances.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, hypertension, and dysphagia, who required maximum assistance with all activities of daily living and specifically two-person assistance for bed mobility and incontinence care, was not provided the required level of assistance. The resident's care plan and Kardex clearly indicated the need for two-person physical assistance for bed mobility and brief changes. Despite this, a CNA entered the resident's room alone to change the bed while the resident was still in it, did not notice the posted sign indicating the required assistance level, and attempted the task without a second staff member present. During the process, the resident rolled off the bed and fell to the floor, hitting their head and complaining of elbow pain. The incident was witnessed by staff who responded to the CNA's call for help. The resident was assessed by a nurse and subsequently sent to the hospital for further evaluation due to being on blood thinners. Interviews with staff confirmed that the resident's need for two-person assistance was documented and known, but the protocol was not followed at the time of the incident.
Medication Storage and Dating Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled in accordance with accepted professional principles in two medication carts reviewed. During observation of medication cart 400B with an LPN, Latanoprost Ophthalmic Solution was found with an open date that was 30 days beyond the date it had been opened. In the same cart, Fluticasone/Salmeterol Diskus and two tubes of Biofreeze Topical Gel were observed without opened dates. The LPN stated the Latanoprost should be discarded and the other opened medications should have been dated when opened. During observation of medication cart 500B with another LPN, ProSource Plus was found with an open date that was 30 days beyond the opened date, and Milk of Magnesia was also observed with an open date that was 30 days beyond the opened date. An open bottle of Nystatin Suspension and Deep Sea Nasal Spray were also present without opened dates. The ICP and DON both stated that multi-use medications should be dated when opened and discarded after 30 days from the opened date. The facility policy reviewed stated multi-use vials are to be dated when first accessed and discarded within 28 days unless the manufacturer specifies otherwise.
Missing EBP Signage for Residents With Wounds
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure Enhance Barrier Precaution (EBP) signage was posted on the doors of two residents with wounds. R30 was admitted and later readmitted with a diagnosis of esophagitis, had intact cognition, required assistance with activities of daily living, and had one stage three pressure ulcer and one venous and arterial ulcer documented on the MDS. The physician ordered daily wound care for an open area on the right posterior lower leg, but the resident’s door was observed without an EBP sign on two separate observations while the resident was in bed watching TV. R99 was admitted with a diagnosis of cerebral infarction, had impaired cognition, required total assistance with activities of daily living, and had one unstageable pressure ulcer documented on the MDS. The physician ordered wound care for an open area to the coccyx with cleansing, Medihoney, Triad cream, and a bordered gauze dressing, yet the resident’s door was also observed without an EBP sign on two separate observations while the resident was in bed on a pressure reducing mattress. When asked about the rooms, the DON stated the residents’ rooms should have EBP signage because the residents had wounds.
Failure to Provide Prescribed Fall Prevention Device
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction, muscle weakness, and impaired cognition (BIMS score 10/15) was not provided with a required fall intervention. The resident, who required staff assistance with bed mobility and transfers, had experienced multiple falls over a six-month period. The resident's care plan included an intervention for a scoop/perimeter mattress, documented as necessary to prevent further falls. Despite this documented intervention, the resident was observed on two occasions lying on a regular mattress rather than the prescribed scoop/perimeter mattress. Nursing staff and the Director of Nursing confirmed that the resident was supposed to have the specialized mattress in place, but it had not been provided. Facility policy requires that residents at risk for falls receive appropriate interventions and assistive devices to prevent avoidable accidents, but this was not implemented for the resident in question.
Plan Of Correction
ELEMENT 1 It is the practice of the facility to implement fall interventions. R704 scoop/perimeter mattress has been placed on R704 bed, care plan reviewed and updated. ELEMENT 2 Residents that currently reside in the facility that require scoop/perimeter mattress have the potential to be affected by this cited practice. Those residents' charts have been reviewed, and those residents have been assessed to ensure scoop/perimeter mattress is in place. Any deficiency has been immediately updated. ELEMENT 3 The Interdisciplinary Team reviewed the Fall Risk/Injury Prevention policy and deemed it appropriate. Nursing staff have been educated on the Fall Risk/Injury Prevention policy with emphasis on ensuring to implement fall interventions, including scoop/perimeter mattress in a timely manner. ELEMENT 4 The DON/designee will complete random audits on 5 residents a week for 4 weeks, then 5 residents a month for 2 months to ensure fall interventions have been implemented in a timely manner including scoop/perimeter mattress for deficient practice will be corrected/updated immediately. The results will also be taken to the Quality Assurance and performance review meeting. The Administrator is responsible for compliance.
Resident Injury During Improper Transfer
Penalty
Summary
The facility failed to ensure safety during a transfer for a resident, resulting in a laceration to the head and an emergency transfer to the hospital. The incident involved a resident who was being transferred from bed to chair using a sit-to-stand lift. The resident reported that the sling broke during the transfer, causing them to fall and sustain a head injury. The resident mentioned that only one staff member was present during the transfer, which was contrary to the facility's policy requiring two staff members for such transfers. The incident report noted that the resident was found lying on the floor with a laceration on the back of their head, surrounded by a CNA, two nurses, and a restorative aide. The resident was alert and oriented but complained of pain to the back of the head. Emergency services were called, and the resident was taken to the hospital, where they received complex sutures for the head laceration. The resident's medical records indicated that they were dependent on assistance for sit-to-stand transfers due to limited mobility and range of motion in their lower extremities. Interviews with facility staff revealed inconsistencies in the adherence to the facility's transfer policy. The Therapy Director and the DON both confirmed that two staff members are required for transfers using a sit-to-stand lift. However, the LPN who responded to the incident confirmed that the CNA was alone during the transfer. The facility's policy on activities of daily living did not specifically address the use of mechanical lifts, which may have contributed to the misunderstanding or misapplication of the transfer procedures.
Failure to Implement Dietary Care Plan Interventions
Penalty
Summary
The facility failed to implement dietary care plan interventions for a resident, identified as R22, who was observed using a straw despite a care plan intervention prohibiting its use. R22, who has diagnoses of dysphagia and multiple sclerosis, was admitted with a diet order specifying a regular diet with mechanical soft texture and thin consistency liquids, with a directive of 'no straws' due to a history of aspiration. This directive was confirmed by the speech language pathologist and was active since March 23, 2023. Despite this, R22 was observed on multiple occasions with a straw in their water cup, which they used to drink, indicating a failure to adhere to the care plan. On several occasions, staff members, including a registered nurse and a licensed practical nurse, were observed removing the straw from R22's water cup after being informed of the care plan directive. The registered dietitian confirmed the necessity of the 'no straw' order due to R22's history of choking. The facility's policy on nutritional management emphasizes individualized interventions, yet the repeated presence of a straw in R22's water cup suggests a lapse in following the prescribed dietary interventions, leading to the deficiency noted in the report.
Failure to Update Care Plan for Resident with Healed Wound
Penalty
Summary
The facility failed to revise an individualized, person-centered care plan for a resident who was observed lying in bed without heel protectors, despite having a care plan that included interventions for pressure ulcer prevention. The resident, who was admitted with Alzheimer's Disease, Hypertension, and Muscle Weakness, was significantly cognitively impaired and required assistance for bed mobility. The care plan, initiated in October 2022, included interventions such as bilateral heel protectors and an air loss mattress to prevent further skin breakdown due to the resident's history of peripheral vascular disease and existing vascular ulcers. However, during observations on two consecutive days, it was noted that the resident's mattress was not an air loss mattress as prescribed. The Director of Nursing and an LPN later explained that the resident no longer needed the air loss mattress as their wound had healed, but acknowledged that the care plan had not been updated to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in the resident's condition, which was not adhered to in this case.
Inaccessible Call Lights for Residents with Impaired Cognition
Penalty
Summary
The facility failed to ensure that call lights were accessible to three residents, all of whom had severely impaired cognition and required assistance for bed mobility. Resident 11's call light was repeatedly observed tied to the bed assist rail and hanging on the floor, out of reach. Despite being awake and conversant, the resident was unable to locate the call light and indicated they would yell to get staff attention. Certified Nurse Assistant A confirmed that the resident did not use the call light and was checked on every two hours instead. Resident 13's call light was found behind the oxygen concentrator on the floor during multiple observations, making it inaccessible. A family member was also unable to locate the call light. Resident 34's call light was observed under the bed covers and on the floor at the foot of the bed, out of reach, during several observations. The resident attempted to locate the call light but was unable to do so and stated they would yell for assistance. The Director of Nursing confirmed that all three residents were capable of using their call lights and that the expectation was for call lights to be within reach. The facility's policy required call lights to be plugged in, functioning, and within reach of residents.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in fall prevention measures. For one resident, who had a history of falls and was at risk due to impaired balance and unsteady gait, the care plan included interventions such as floor mats, a perimeter mattress, and ensuring the call light was within reach. However, observations revealed that the resident was on a regular mattress instead of the prescribed perimeter mattress, and the call light was not within reach, contributing to a fall that resulted in facial bruising. The Director of Nursing (DON) later confirmed that the correct mattress was not transferred with the resident during a room change, and unit managers were responsible for ensuring interventions were in place. Another resident, also at risk for falls due to confusion, muscle weakness, and poor balance, was observed in a bed that was not in the low position as required by their care plan. The bed was found to be malfunctioning, preventing it from being lowered. The DON and Maintenance Director acknowledged that a work order had been submitted to address the issue. The facility's policy emphasizes the importance of implementing comprehensive, person-centered care plans with measurable objectives, but these were not effectively executed for the residents in question.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to secure medications on three separate medication carts throughout the facility, as observed by surveyors. On June 18, 2024, at 9:30 AM, an unlabeled medication cart was found unlocked and unattended in a hallway with resident rooms, and it was only locked by an unknown staff member two minutes later. Later that day, at 11:42 AM, another unlabeled medication cart was observed unlocked and unattended in a hallway containing resident rooms 501-509. Shortly after, at 11:45 AM, a third unlabeled medication cart was found unlocked and unattended outside a resident room, with an unidentified nurse acknowledging the mistake. The facility's policy, as provided, requires medications and biologicals to be stored in secured, locked locations accessible only to designated staff, which was not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four Chaplains Nursing Care Center | 1.1 mi | ★★★★★ | 8 | 0 |
| Regency At Livonia | 1.7 mi | ★★★★★ | 12 | 0 |
| Majestic Care Of Livonia | 2.7 mi | ★★★★★ | 12 | 0 |
| Livonia Woods Nursing And Rehabilitation | 3 mi | — | 0 | 0 |
| Optalis Health And Rehabilitation Of Dearborn Heig | 3.4 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.