Foundation Park Care Center

Inspectors wroteBased on staff interview, pharmacist interview, review of the Narcotic Shift Count sheet and review of facility policy, the facility failed to ensure the security of controlled medications by maintaining an uninterrupted chain of custody of the medication cart keys. This had the potential to affect six (#33, #30, #62, #10, #28 and #63) residents who had physician ordered controlled medications stored in the Hall-A medication cart. The facility census was 91.

Inspectors wroteBased on review of the medical record, staff interview, and policy review, the facility failed to ensure documentation of meal intakes were completed in the medical record. This affected three (#28, #35, #86) of three residents reviewed for meal intake documentation. The facility census was 83.

Inspectors wroteBased on observations, record review, staff interviews, consultant interviews, and policy review, the facility failed to ensure the dishwashing machine was functional, failed to ensure appropriate hand hygiene was practiced during meal service, and failed to ensure emergency water was stored in a sanitary environment. This had the potential to affect all residents in the facility. Additionally, the facility failed to ensure residents received food without foreign substances. This affected one (#73) of four residents reviewed for food and nutrition. The facility census was 87.

Inspectors wroteBased on observation, staff interview, medical record review, policy review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure a risk assessment was developed with facility specific measures to prevent the growth of Legionella. Additionally, the facility failed to ensure monitoring of Legionella control measures. This had the potential to affect all residents. Furthermore, the facility failed to wear proper personal protective equipment (PPE) while providing care to residents with physician orders for enhanced barrier precautions (EBP). This affected two (#11 and #22) of four residents reviewed for EBP. The facility identified nine residents (#5, #6, #60, #13, #24, #12, #47, #11, and #22) requiring EBP. [...]

Inspectors wroteBased on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects and adverse effects. This affected three (#15, #35, and #10) of five residents reviewed for unnecessary medications. The facility identified 66 residents receiving psychotropic medications. The facility census was 87.

Inspectors wroteBased on observations, record reviews, staff interviews, and policy reviews, the facility failed to ensure dependent residents received assistance with activities of daily life. This affected five (#65, #82, #73, #53, and #11) of six residents reviewed for activities of daily living (ADLs). The facility census was 87.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure pressure reducing measures were implemented as ordered. This affected three (#22, #2, and #5) of four residents reviewed for pressure ulcer prevention. The facility census was 87.

Inspectors wroteBased on observations, record review, staff interview, recipe review, menu review, and policy review, the facility failed to ensure staff followed menus and recipes for residents on a pureed diet. This affected 10 (#8, #11, #19, #29, #39, #42, #49, #53, #60, and #65) residents who received the pureed diet. Additionally, the facility failed to ensure residents received double portions as ordered by the physician. This affected one (#65) of four residents reviewed for food and nutrition. The facility census was 87.

Inspectors wroteBased on observation, staff interview, record review, review of the wheelchair cleaning schedule, and policy review, the facility failed to ensure floor mats and wheelchairs were maintained in a clean sanitary condition. This affected three (#22, #65, and #82) of three residents reviewed for environment. The facility census was 87.

Inspectors wroteBased on observation, record review, staff interview, and policy review the facility failed to ensure accurate resident assessments were completed. This affected one (#05) of six residents reviewed for accidents. The facility census was 87.

Inspectors wroteBased on observations, medical record review, staff interview, and policy review the facility failed to implement fall safety precautions. This affected one (#5) of three residents reviewed for falls. The facility census was 87.

Inspectors wroteBased on observation, medical record review, staff interview, review of the Centers for Disease Control (CDC) recommended guidelines for indwelling urinary catheter insertion and maintenance, and policy review, the facility failed to provide an indwelling urinary catheter (IUC) securement device. This affected one (#42) of one resident reviewed for indwelling urinary catheters. The facility identified one resident with an indwelling urinary catheter. The facility census was 87.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents received enteral nutrition (tube feeding) as ordered by the physician. This affected one (#22) of two residents reviewed for tube feedings. The facility census was 87.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure a resident was receiving oxygen therapy per physician orders. This affected one (#56) of one resident reviewed for respiratory. The facility identified six residents who required supplemental oxygen. The facility census was 87.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to secure a provider agreement with a hemodialysis provider prior to the current annual survey. Additionally, the facility failed to ensure collaborative communication was shared between the facility and the hemodialysis center. This affected one (#12) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis services The facility census was 87.

Inspectors wroteBased on observation, medical record review, resident representative interview, and staff interview, the facility failed to ensure specific interventions were provided to address triggers and care for post-traumatic stress disorde (PTSD). This affected one (#10) of one resident reviewed for PTSD care and treatment. The facility census was 87.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure nutrition assessments were completed accurately and updated with new diet orders. This affected one (#65) for four residents reviewed for food and nutrition. The facility census was 87.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure interventions were implemented to prevent a pressure ulcer from increasing in size and stage. This resulted in actual harm beginning on 12/22/25 when one resident (#01), who was identified at low risk for pressure ulcer development, was discovered with a Stage II pressure ulcer which increased in size and depth and was assessed as an unstageable pressure ulcer with malodorous necrotic tissue 19 days after being discovered. The facility failed to provide any reassessment of the resident's condition and for a possible source of the pressure ulcer and no nutritional assessments had been completed from the time when the pressure ulcer was initially identified. This affected one (#01) of three residents reviewed for pressure ulcer prevention and wound healing. [...]

Inspectors wroteBased on medical record review, staff interview, review of facility documentation, and review of facility policy, the facility failed to ensure the physician and responsible party were timely notified when a resident was discovered unresponsive on the floor with a laceration to the head. This affected one (#2) of three residents reviewed for timely notification in a facility census of 89.

Inspectors wroteBased on medical record review, staff interview, review of facility incident report, review of hospital documentation, and review of facility policy, the facility failed to provide appropriate treatment and neurological assessments following the discovery of a resident on the floor unresponsive with a laceration to the head. This affected one (#2) of three residents reviewed for timely care and treatment. The facility census was 89.

Inspectors wroteBased on medical record review, review of an incident report, review of witness statements, staff interview, and review of facility policies, the facility failed to ensure notifications were made to resident representatives and hospice providers following an incident of a resident being lowered to the ground. This affected one (#12) of five residents reviewed for notifications. The facility census was 89.

Inspectors wroteBased on medical record review, review of an incident report, review of written statements, staff interview, and review of a facility policy, the facility failed to thoroughly assess residents following an incident where the resident was lowered to the ground. This affected one (#12) of three residents reviewed for transfers. The facility census was 89.

Inspectors wroteBased on closed medical record review, staff interview, review of a written staff statement and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call nine-one-one (911) for Emergency Medical Services (EMS) assistance for Resident #100, who was found unresponsive, absent of breaths, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when Licensed Practical Nurse (LPN) #400 went to Resident #100's room to check his blood sugar levels and found the resident to be unresponsive and absent of vital signs. [...]

Inspectors wroteBased on open and closed medical record review, staff interview, review of a facility incident report, review of the Enhanced Information Dissemination and Collection (EIDC) system (system for reporting information) and review of the facility policy, the facility failed to report incidents of potential abuse and/or neglect to the State Survey Agency (SSA). This affected two (#100 and #68) of five residents reviewed for abuse. The facility census was 86.

Inspectors wroteBased on open and closed medical record review, staff interview, review of a facility investigation and review of facility policy, the facility failed to initiate and thoroughly investigate potential neglect and physical abuse. This affected two (#100 and #68) of five residents reviewed for abuse. The facility census was 86.

Inspectors wroteBased on closed medical record review, staff interview, review of facility job descriptions, review of staff cardiopulmonary resuscitation (CPR) certifications and review of facility policy, the facility failed to ensure staff were competent and compliant with with implementing CPR per the physician orders and further failed to ensure nurse supervisors were qualified per the facility job description qualifications. This affected one (#100) of three residents reviewed for Advanced Directives. The facility census was 86.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to implement the facility policy regarding the requirement to report a resident to resident altercation to the state agency. This affected one resident (#15) reviewed for abuse. The facility census was 92.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to report a resident to resident altercation. This affected one resident (#15) reviewed for abuse. The facility census was 92.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to ensure treatments were provided with a physician's order. This affected one (#14) of four residents reviewed for physician orders. The facility census was 88.

Inspectors wroteBased on observation, staff interview and review of the facility's recipes, the facility failed to ensure portion sizes were followed when serving all diet textures. This affected 83 residents identified by the facility as receiving food from the kitchen. Additionally, the facility failed to ensure recipes were followed during preparation of pureed foods. This affected five (#18, #20, #21, #38, and #287) of five residents identified by the facility as having a physician ordered pureed diet. The facility census was 83.

Inspectors wroteBased on observation, staff interview, review of the medical record and review of the facility policy, the facility failed to ensure floors were adequately maintained. This had the potential to affect all 83 residents of the facility. Additionally, the facility failed to ensure resident rooms were free from odors. This affected one (#43) one one resident reviewed for room odors. The facility census was 83.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were secure at all times and further failed to ensure medications were stored in approved and labeled containers. This affected thirteen (#5, #8, #12, #13, #23, #24, #36, #38, #52, #58, #61, #69 and #71) residents of thirteen residents observed for the storage of medication. The facility census was 83.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure a copy of the advanced directives were in the resident's medical record. This affected two (#59 and #236) of three residents reviewed for advanced directives. The facility census was 83.

Inspectors wroteBased on observation, staff interview, review of a hospital referral and medical record review, the facility failed to ensure accurate skin assessments were completed upon admission. This affected one (#236) of two residents reviewed for skin conditions. The facility census was 83.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to maintain appropriate physician orders, failed to accurately assess a dialysis access sites and further failed to ensure a dialysis catheter site was covered. This affected one (#17) of one resident reviewed for dialysis. The facility identified one resident on dialysis. The facility census was 83.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure non-pharmacological behavioral interventions were assessed or implemented to address resistance to care resulting in lack of timely care and/or treatment. This affected one (#46) of four residents reviewed for behavioral services. The facility census was 83.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure an accurate Nutritional Assessment was completed. This affected one (#50) of four residents reviewed for nutrition. The facility census was 83.

Inspectors wroteBased on medical record review, family interview, and staff interview, the facility failed to ensure resident/family concerns were resolved timely. This affected one resident (#65) of three residents reviewed for grievances. The facility census was 84.

Inspectors wroteBased on observation, staff interview, and review of facility policy the facility failed to ensure resident rooms and resident equipment were appropriately clean. This affected three residents (#10, #65 and #79) of four residents reviewed for a clean environment. The facility census was 84.

Inspectors wroteBased on observation, staff interview, and sanitizer manufacturer instructions for use, the facility failed to maintain the facility food service kitchen environment, equipment and cleaning solution in a sanitary manner. This affected all 72 residents who received food from the facility. One resident (#34) was identified by the facility to receive nothing by mouth.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected all residents residing in the facility. The facility census was 73.

Inspectors wroteBased on observation, staff interview, and local health inspection documentation, the facility failed to maintain the facility food service kitchen environment free of pests. This affected all 72 residents who received food from the kitchen. One resident (#34) identified by the facility to receive nothing by mouth. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure residents receiving psychoactive medications and psychiatric symptoms were consistently monitored for effective treatment and potential side effects of treatment medications, and the presence of adequate behaviors to warrant the use of psychotropic medications. This affected four (#17,#59, #62, #65) of five residents reviewed for the administration of unnecessary medications. The facility identified 38 residents who received psychotropic medications. The facility census was 73.

Inspectors wroteBased on observation, staff interview, and menu review, the facility failed to ensure all items listed on the menu were provided to residents. This affected 15 residents (#23, #46, #124, #1, #4, #15, #19, #20, #25, #27, #37, #41, #47, #50, and #52 ) receiving altered texture diets.

Inspectors wroteBased on medical record review, staff interview, review of Situation, Background, Assessment Recommendation (SBAR) documents and review of facility policy and procedure, the facility failed to ensure residents met criteria prior to the initiation of antibiotics. This affected four (#5, #34, #67 and #70) of four residents reviewed for antibiotic use. The facility identified seven residents ordered antibiotics. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview, and review of the facility COVID-19 testing line list, the facility failed to ensure resident's COVID-19 testing was documented in the medical record. This affected two (#29 and #62) of two residents reviewed for COVID-19, with the potential to affect all residents of the facility. The facility census was 73.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents were notified when their personal funds account balance was within $200.00 of the Medicaid resource limit. This affected three (#8, #15 and #23) of five residents reviewed for personal funds. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to notify the physician of a significant medication error. This affected one (#59) of five residents reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure privacy for residents dependent for care. This affected two (#1 and #13) of two residents reviewed for privacy. The facility census was 73.

Inspectors wroteBased on observation, medical record review, staff interview, manufacturer instructions for use, and facility policy, the facility failed to transport residents in the hallway utilizing the appropriate device in a safe manner. This affected one (#44) of four residents reviewed for accidents in a facility census of 73.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to ensure the care and management and continued need for an indwelling urinary catheter for Resident #63. This affected one resident (Resident #63) of one resident reviewed for having an indwelling urinary catheter. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility pharmacy policies, the facility failed to ensure intravenous (IV) administration tubing was changed every 24 hours and failed to change dressings at IV cites per the policy. This had the potential to affect two (#224 and #12) out of two residents reviewed for IV medications. The facility census was 73.

Inspectors wroteBased on observation, medical record review, resident interview, and staff interview, the facility failed to implement interventions for the treatment of depressed mood. This affected one (#65) of one resident reviewed for mood and behavioral interventions. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure medications were administered per physician order. This affected one (#62) of five residents reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure residents were free from significant medication errors. This affected one (#224) resident observed during medication administration and two (#224 and #59) residents reviewed for medication administration. The facility census was 73.