Foundation Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Foundation Skilled Nursing, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 9, 2025

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one of seven residents (Resident 17) when Resident 17 was assessed with poor safety awareness, did not use safe techniques in self-transfers, had unsteady gait, and suffered multiple falls on 11/18/25, 11/22/25,11/23/25 and 11/24/25. Resident 17 had been determined as high risk for falls on quarterly assessment dated [DATE]. The facility failed to follow its facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, when the facility did not implement effective interventions to prevent falls, including adequate supervision, addressing the cause of frequent self-transferring attempts and reviewing medication for a possible cause consistent with… […]

• Actual harm, isolatedF689Aug 12, 2025

  Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for one of four sampled residents (Resident 1) when Resident 1 was assessed as being at high risk had poor safety awareness (not paying attention to the dangers around you, a history of self-transferring to get to the bathroom, frequent urination (act of releasing liquid waste that your kidneys make to remove excess fluids and waste products from your body) and needed to be supervised by a staff member during transfer and the facility did not implement individualized interventions to prevent falls, including supervision and addressing the cause of frequent self-transferring attempts, consistent with the resident's needs, goals and care according to the… […]

• Actual harm, isolatedF600Feb 23, 2024

  Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when Resident 1 experienced an incident on 10/26/23 where Resident 2 entered Resident 1 ' s room, unattended and unsupervised, and used a stuffed cat/toy that belonged to Resident 1 to inflict facial and eye injuries. On 2/1/24, Resident 1 was found to have facial and eye injuries of unknown origin. The unwitnessed incident resulting in Resident 1 ' s facial injuries was not reported immediately by CNA 1 in accordance with facility policy and procedure. These failures resulted in Resident 1 to experience avoidable physical, psychosocial, and emotional harm. […]

• Actual harm, isolatedF758Jul 15, 2022

  Based on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (medications used to treat [CONDITION(S)]-which is a condition that affects the mind, where there has been some loss of contact with reality) medications and ensure three of three sampled residents (Resident 38, Resident 47, and Resident 150) were free from unnecessary medications when: 1. For Resident 47, staff administered [MEDICATION(S)] (an antipsychotic medication used to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without monitoring for side effects. 2. […]

• No harm, potential for more than minimal, widespreadF658Dec 9, 2025

  Based on observation, interview, and record review, the facility failed to follow policy and procedures to meet professional standards of quality for one of four sampled residents (Resident 64), when Resident 64's admission medications were not available on the next dose as ordered by the physician. Resident was admitted to the facility on [DATE].These failures had the potential to place Resident 64 at an increased risk of health complications and change of condition resulting in hospitalization. Findings:During a concurrent observation and interview on 12/2/25 at 10:02 a.m. with Resident 64, in Resident 64's room, Resident 64 was awake lying in bed. Resident 64 was alert oriented x 4 (refers to someone who is alert and oriented to person, place, time and event). […]