Care One At Essex Park

Based 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. Findings include:Review of the Facility's Job Description titled, Certified Nursing Assistant, which was provided by the facility indicated it was last updated in 12/2006, identified that essential duties and responsibilities of a Certified Nursing Assistant (CNA) consisted of the following:-Perform all assigned tasks in accordance with the Facility's Policies and Procedures, and as instructed by your supervisors.-Report all resident changes in condition promptly to the Nurse Supervisor/Charge Nurse.-Assist in preparing the resident for a physical examination.-Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include:Resident #14 was readmitted to the facility in January 2026 with diagnoses that included Post Traumatic Stress Disorder, anxiety, major depressive disorder, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/26, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Review of Resident #14's psychiatric Nurse Partitioner (NP) progress note, dated 3/21/26, indicated GDR Rationale(s): Recommend GDR decrease the Aripiprazole (antipsychotic medication) to 2.5 mg (milligrams) every other day for 1 week, then D/C (discontinue). Continue to monitor mood & behavior. Further review of the psych NP note indicated: Review/Discussion:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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).Findings include:Review of the facility policy titled 'Care Plans, Comprehensive Person-Centered' revised in March 2022 indicated the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of the facility policy titled 'Dementia Care Unit Activities Program' with a revision date of 7/3/2018 indicated the following:-The Activities program on the Dementia Care Unit is designed to meet the current and changing needs of individuals with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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).Findings include:Review of the facility policy titled 'Care Plans, Comprehensive Person-Centered' revised in March 2022 indicated the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.-Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes.Review of the facility policy titled 'Dementia Care Unit Activities Program' with a revision date of 7/3/2018…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Resident #11 was admitted to the facility in June 2025 with diagnoses that included muscle weakness, type 2 diabetes and dementia. Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident had one or more unhealed pressure ulcers, including one stage 4 pressure ulcer that was present on admission to the facility. Review of the most recent Norton Assessment (an assessment to assess a resident's risk for skin breakdown and the development of pressure ulcers), completed 7/23/25, indicated a risk score of 8 indicating high risk for pressure ulcer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include:Resident #11 was admitted to the facility in June 2025 with diagnoses that included anxiety, insomnia and dementia. Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS failed to indicate any behaviors were present during the look back period. The MDS further indicated that the Resident received antidepressant medications. Review of the Behavioral Health Note, dated 2/20/26, indicated the following:-Plan/ Recommendations:-Increase the Trazodone (antidepressant medication) to 50 mg HS (milligrams at bedtime) for insomnia.-Continue to monitor his/her mood & behavior. -Provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident #83 was admitted to the facility in March 2024 with diagnoses including retention of urine, obstructive and reflux uropathy. Review of Resident #83's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 11 out of 15 on the Brief Interview for Mental Status (BIMS) score indicating that he/she had moderate cognitive impairment. The MDS further indicated the Resident had an indwelling foley catheter. Record review of a document titled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding. 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 tube feeding. Review of Resident #95 diet care plan date revised 10/4/21 indicated the following interventions: -Enteral nutrition per physician's orders -Solids puree solids -Liquid consistency: Mildly Thick Review of Resident #95…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of facility policy titled Administering Medications, revised April 2019, indicated, but was not limited to: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders. 1.) Resident #30 was admitted to the facility in September 2023 with diagnoses including asthma and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #12 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled Medication Labeling and Storage, revised February 2023, indicated, but was not limited to: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. -The nursing staff is responsible for maintaining medication storage. -Compartments (including carts) containing medications and biologicals are locked when not in use, and the trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1.) The surveyor made the following observations on the [NAME] Unit: -On 5/1/24 at 9:00 A.M., the surveyor observed the medication cart on A side of [NAME] unit unlocked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. During an interview on 5/2/24 at 10:24 A.M., Certified Nursing Assistant (CNA) #1 said documentation for all ADLs should be complete and no holes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.