Care One at Essex Park

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was having difficulty moving his/her bowels, the Facility failed to ensure he/she was provided care and treatment in accordance with acceptable standards of practice, when a Certified Nurse Aide (CNA) used her fingers to digitally disimpact (remove harden mass of feces from rectum) Resident #1, which was not within a CNA's scope of practice or job description and per the facility, was not a procedure that CNA's could perform.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#14) was free from unnecessary antipsychotic medications by ensuring the psychiatric Nurse Practitioner recommendations for a gradual dose reduction (GDR) were communicated to the Resident's physician, out of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement a plan of care for one Resident (#143) out of a sample of 35 residents. Specifically, the facility failed to implement a sensory diet plan of care (a personalized, occupational therapist-designed activity plan providing specific sensory input (visual, auditory, olfactory, tactile, proprioceptive and gustatory). It helps regulate the nervous system, improving focus, behavior, and emotional control).

Inspectors wroteBased on observation, interview and record review, the facility failed to reassess and revise a plan of care for one Resident (#143) out of a sample of 35 Residents. Specifically, the facility failed to revise a sensory diet plan of care (a personalized, occupational therapist-designed activity plan providing specific sensory input (visual, auditory, olfactory, tactile, proprioceptive and gustatory). It helps regulate the nervous system, improving focus, behavior, and emotional control).

Inspectors wroteBased on record review and interview the facility failed to provide care and services consistent with professional standards of practice for one Resident (#11) with a pressure ulcer, out of a total sample of 35 Residents. Specifically, for Resident #11 the facility failed to implement wound treatment recommendations from the consulting wound physician.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that medications were accurately implemented by nursing for one Resident (#11), out of a total sample of 35 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to accurately implement a medication recommendation from Behavioral Health Services.

Inspectors wroteBased on observations, interviews, records, and policies reviewed, the facility failed to ensure that one Resident (#95) out of a total sample of 34 residents, maintained acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #95's weight was monitored when a weight change occurred, per facility policy, and resulted in significant weight loss and failed to notify the physician after significant weight loss was identified after Resident #95's gastrostomy tube (a tube inserted into the stomach to provide nutrition) was accidentally removed and not replaced.

Inspectors wroteBased on observations, interviews, policy and record reviews, the facility failed to ensure that one Resident (#95) of one applicable resident, in a total sample of three residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that fluids were administered and monitored to maintain acceptable parameters of hydration, after the tube was dislodged on 3/8/24 resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specifically formulated liquids that are injected into a vein to prevent or treat dehydration) for the Resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide care and service for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#83), out of a total sample of 34 residents. Specifically, for Resident #83, the facility failed to ensure the physician's order for changing/inserting the Foley catheter included catheter size/type and balloon size.

Inspectors wroteBased on record review and interviews, the facility failed to notify the physician of a significant weight loss for one Resident (#95) out of a total sample of 34 residents. Specifically, the facility failed to notify physicians of the significant weight loss on Resident #95 who was totally dependent on tube feeding for his/her daily nutritional needs.

Inspectors wroteBased on observations, policy review, record review, and interviews for two Residents (#30 and #138) out of five Residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of four nurses observed made three errors out of 29 opportunities resulting in a medication error rate of 10.34%. Specifically, 1.) For Resident #30, the nurse administered the incorrect form and incorrect medication. 2.) For Resident #138, the nurse administered to incorrect medication.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure medication carts on two of four units.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records for one Resident #95 out of a total sample of 34 residents. Specifically, the facility failed to complete daily documentation for Activities of Daily Living (ADLs). Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted which indicated the Resident had memory problem and was cognitively impaired. The MDS further indicated that the Resident was dependent on staff for total care. Review of the eating documentation section on the document titled, 'Documentation Survey Report' for February, March and April 2024, indicated documentation was incomplete for 21 shifts out of the 90 days. [...]