Care One at Essex Park

In the surveyor’s words

From the most serious findings on record at Care One at Essex Park, in the surveyor’s own words.

• Actual harm, isolatedF692May 2, 2024

  Based 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. […]

• Actual harm, isolatedF693May 2, 2024

  Based 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… […]

• Actual harm, isolatedF580Feb 14, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted to the Facility for a short term respite stay, and had a history of a seizure disorder for which he/she required administration of anticonvulsant/anti-seizure medication, the Facility failed to ensure nursing notified the physician when his/her anticonvulsant/anti-seizure medication was not administered, per physician's orders. Resident #2's admission physician's orders indicated to administer Vimpat (anticonvulsant medication) 100 milligrams (mg) twice daily. […]

• Actual harm, isolatedF760Feb 14, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted for short term respite care, and whose diagnoses included a seizure disorder, the Facility failed to ensure he/she was free of significant medication error, when he/she was not administered Vimpat, (anticonvulsant medication) 100 milligrams (mg) twice daily, per physician's orders. Resident #2 missed 10 consecutive doses of Vimpat, and although nursing documented it was unavailable, nurses assigned to care for Resident #2 did not notify the physician to report the medication was not being administered or to obtain additional orders related to the omitted doses of Vimpat. […]

• No harm, potential for more than minimal, patternF584Mar 1, 2023

  Based on observations and interviews, the facility failed to maintain a homelike environment on 2 of 4 resident units. Findings include: 1. During environmental rounds on 3/1/23 at 9:40 A.M., the following was observed on the first-floor [NAME] unit: *In room [ROOM NUMBER], wallpaper was peeling behind the B bed. *In room [ROOM NUMBER], wallpaper was peeling behind the A bed. *In room [ROOM NUMBER], the baseboard at the corner of the wall between the bathroom and the A bed was peeling away from the wall. *In room [ROOM NUMBER], the A bed television (TV) table had many scratches all over it. […]