Ivy Park at Seven Oaks

Keep bath, laundry and kitchen floors clean

Based on observation, mold was observed in and around three of the kitchen floor sink drain and was observed dirty, which poses/posed a potential Health, Safety, and Personal Rights risk to the residents.

Give PRN medication by physician order

Based on interviews conducted, records review, and observation, R1’s Senna-Time medication bubble pack with quantity of 15 was first administered daily starting on 12/11/25 at 08:30AM. Bubble pack was checked and verified by Health Service Director and LPA, 8 tablets were administered with 7 tablets left in the bubble pack, which poses an immediate health and safety risk for the person in care.

Provide resident hot water for personal care

Based on observation, hot water temperature in memory care unit measured at 130.3 degrees F in room 27, 125.3 degrees F in room 46, and 122.5 degrees F in room 12, which poses/ posed a potential health and safety risk for the person in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPA observed tools and box cutters in room 112, a cleaning bottle in room 107 bathroom cabinet, and small knives stored in room 213 kitchen drawers, unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Give PRN medication by physician order

Based on records review and observation, R1’s medication Gabapentin 300 mg, R2’s medication Levothyroxine 100mcg, R2 medication Meloxicam 7.5 mg, R3 medication Divalproex 500 mg, and R3’s medication Vitamin D-3 2,000U were not administered as instructed by physician, which poses an immediate health and safety risk for the person in care.

Food storage temperature control requirements

Based on interviews conducted, observation, and records reviewed, the facility walk in freezer was observed at 38 degrees F. Facility record show walk-in freezer temperature maintained between 2.4 and 34.9 degrees F, which posed/ poses a potential health and safety risk for the person in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed knives and cleaning chemicals unlock in resident room 105, 112, and 218 stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed in room 112, medications on the kitchen counter, in bathroom, and in kitchen cabinet unlock. Medications were observed in room 105 in bathroom cabinet unlock. Medications were also observed unlock in kitchen cabinet in room 218. Medications were observed unlock and accessible to residents poses an immediate health, safety or personal rights risk to person in care.

Limit staff assistance with self-administered drugs

87465(a)(5) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on interview, R1 was administered R2’s medication by S1 which poses an immediate health and safety risks to persons in care.

87413(a)(2) a) In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.This requirement is not met as evidenced by: Based on interview and record review, staff did not provide care and supervision when memory care R1 left the facility unsupervised on 07/10/23 at approximately 07:35PM. The facility was not aware R1 went AWOL until approximately at 07:47 PM when the facility was notified by the neighboring building that the resident was in their building lobby. This poses an immediate health and safety risks to persons in care.

Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 1. A comprehensive description of and the corresponding fee schedule for…items and services not included in the fees for basic services shall be listed.This requirement was not met by: Based on interview and records reviewed, the one-on-one charges were not outlined and not agreed by responsible party or resident in the admission agreement. The resident was charged for one on one 24-hour champion care which possess a potential health and safety and personal rights risk to the resident in care.