Foundation Park Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Aug 4, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Jun 15, 2021

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interview, medical record review, review of the facility's Self-Reported Incident (SRI) and investigation, and review of the facility's policy for abuse, the facility failed to ensure one female resident (#100), who had severe cognitive impairment and wandered, was free from sexual abuse from one male resident (#110), who displayed signs of sexual inappropriacy and whose plan of care was absent for interventions related to sexual behaviors. This resulted in Immediate Jeopardy and the likelihood of serious harm on 05/09/21 at 11:08 A.M. when staff found Resident #110 on top of Resident #100 in Resident #110's bed. […]

• Actual harm, isolatedF686Feb 26, 2026

  Based 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. […]

• Actual harm, isolatedF689Aug 30, 2023

  Based on observations, medical record review, staff interview, and review of facility policy, the facility failed to ensure a visually impaired resident who was at risk for falls, was provided a proper room set up to prevent falls. This resulted in actual harm when Resident #10 had a room change on 08/03/23 at 11:45 A.M., fell in the new room on 08/03/23 at approximately 3:50 P.M., was transported to the hospital and found to have a fracture of the right humerus (shoulder). This affected one (Resident #10) of three residents reviewed for falls. The facility census was 88. Finding include: Review of the medical record for Resident #10 revealed an admitted [DATE]. […]

• Actual harm, isolatedF689Jun 20, 2023

  Based on medical record review, staff interview, review of the facility's incident report, review of the hospital record, and review of a personnel file, the facility failed to ensure a resident was provided with sufficient staff supervision when positioned in bed during direct care. This resulted in Actual Harm when Resident #74 sustained multiple fractures, when State tested Nursing Assistant (STNA) #117 rolled the resident away from the STNA during care, the resident rolled off the bed, landed on the floor, and was subsequently sent to the local hospital where the resident was diagnosed with a fractured right hip, pelvis, and right knee. This affected one resident (#74) of five residents reviewed. […]