The Enclave

In the surveyor’s words

From the most serious findings on record at The Enclave, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 4, 2024

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, in that: 1. The facility failed to provide adequate supervision of Resident #1 on 02/25/2024 resulting in the resident being found outside of the facility on 02/25/2024 at 4:51 PM. 2. The facility failed to provide adequate supervision of Resident #1 on 04/28/2024 resulting in the resident being found outside of the facility on 04/28/2024 at 9:31 PM. An IJ was identified on 05/02/204. The IJ template was provided to the facility on [DATE] at 4:15 PM. […]

• No harm, potential for more than minimal, widespreadF812Jun 28, 2024

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The CDM wore a hair restraint that did not cover all his hair. 2. In the freezer, there was frozen raw beef stored over fully cooked frozen pies. 3. In the walk-in cooler, there were: a. Uncovered foods of 3 trays of pie desserts, 2 trays of bowels of fruits, and 1 tray of plates of salad. b. Cheese that was inappropriately stored. c. The CDM revealed he did not label prepare foods with a discard date. 4. In the dish room, the temperature log of the dishwashing machine had the wrong temperature 5. […]

• No harm, potential for more than minimal, patternF641Aug 27, 2025

  Based on observations, interviews and record reviews, the facility failed to provide assessments that accurately reflect the resident's status for three (Residents #41, #55 and #34) of 32 residents reviewed for MDS assessment accuracy. 1.Resident #41's MDS assessment did not accurately reflect she had an indwelling urinary catheter. 2. Resident #55's admission MDS assessment did not accurately reflect she had an indwelling urinary catheter. 3.Resident #34's MDS assessment did not accurately reflect she took an opioid medication. This deficient practice affects residents with MDS assessments and could result in missed or inappropriate care. […]

• No harm, potential for more than minimal, patternF656Aug 27, 2025

  Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three ( Residents #17, #41 and #119) of 32 residents reviewed for comprehensive care plans. The facility failed to provide Resident #17 a call bell instead of a call light which was reflected in his comprehensive person-centered care plan. 2. The facility failed to reflect Resident #41 had an indwelling urinary catheter in her comprehensive person-centered care plan. 3. […]

• No harm, potential for more than minimal, patternF755Aug 27, 2025

  Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 (Resident #18, #150, and #1) of 7 residents reviewed for pharmacy services. 1. The facility failed to re-order on time Resident #18's Janumet 50-500 mg medication for diabetes. 2. The facility failed to re-order on time Resident #150's Carboxymethlcellulose sodium 0.5% eye drops for dry eyes. 3. The facility to ensure Resident #1's insulin Lispro KwikPen for diabetes had open date of [DATE], stored inside the 200-unit C-hall nursing cart was not expired. […]