Health inspection·August 29, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure treatments were provided with a physician's order. This affected one (#14) of four residents reviewed for physician orders. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/18/23 with a readmission date of 04/1/24 with diagnoses of Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #14 had impaired cognition. Review of the physician orders dated 07/01/24 through current revealed no orders for Nystatin powder (a powder used to treat fungal or yeast infections on the skin). Review of the Medication Administration Record and Treatment Administration Record dated August 2024 revealed no documentation Resident #14 received Nystatin powder. Review of the Shower/Skin Assessment completed 08/01/24 revealed Resident #14 had dry/flaky skin and redness with excoriation and imprint made to bilateral shoulders, back and underneath both breasts from bra. Resident #14's bra was removed. Review of the Shower/Skin Assessment completed 08/05/24 revealed no skin areas of concern. Review of a progress note dated 08/01/24 revealed Resident #14 had an imprint to her shoulders, back and under both breasts from her bra. Nystatin powder was applied and the bra was removed. Interview on 08/29/24 at 10:03 A.M. with State Tested Nursing Assistant (STNA) #101 revealed she was providing care to Resident #14 when she found marks on her shoulders and under her breasts. STNA #101 stated she felt Resident #14's bra had been on too long or was too small. STNA #101 reported the skin concerns to the nurse who provided treatment to the area. STNA #101 stated it occurred approximately two or three weeks previously and the area was resolved. Interview on 08/29/24 at 2:45 P.M. with the Director of Nursing (DON) with concurrent review of Resident #14's electronic medical record confirmed the nurse documented Nystatin powder was applied, and further confirmed no physician order was entered for Resident #14 to receive Nystatin powder. The DON stated a physician order should be in place before providing Nystatin powder. Continued (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365752 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365752 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foundation Park Care Center 1621 S Byrne Rd Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)