North Park Post-Acute

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of care were met for 1 of 3 sampled residents (Resident 1), when:1. Resident 1 was administered insulin (medication that lowers blood sugar level) and Depakote (medication used to treat seizure disorder) without a physician's order; and,2. The facility failed to consistently monitor Resident 1 for adverse effects after she returned from the hospital. This failure had the potential to cause hypoglycemia (blood sugar below 70 which can cause shaking, sweating, and rapid heartbeat) and other adverse medication side effects which could negatively impact Resident 1s health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Resident or Responsible Party (RP, someone who can help the resident and, as necessary, make decisions for the resident) was informed and consented to the use of psychotropic (drugs that affect a person's mind, emotions, and behavior) medications for five of 46 sampled residents (Resident 2, Resident 112, Resident 8, Resident 3, and Resident 19). Resident 2,Resident 112,Resident 8,Resident 3,Resident 19,These failures had the potential for not honoring the resident's right to be informed about his or her medical treatment, including medication side effects or other alternative options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of six of 46 sampled residents (Resident 28, Resident 112, Resident 72, Resident 114, Resident 115, and Resident 117) when the following residents did not have access to their call lights (devices used to contact staff for assistance):1. Resident 28,2. Resident 112,3. Resident 72,4. Resident 114,5. Resident 115,6. Resident 117,These failures placed Resident 28, Resident 112, Resident 72, Resident 114, Resident 115, and Resident 117 at increased risk for unmet care needs, delayed staff response, falls, and potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for three of 46 sampled residents (Resident 18, Resident 82, Resident 95) when,A bowel movement (BM) was found in the facility's South Hall, In room [ROOM NUMBER], the window blinds were broken and there were floor tiles missing next to Resident 82's bed, In room [ROOM NUMBER], a tall dresser used by Resident 18 was missing knobs on one of the drawers and the bottom drawer had the front panel broken and laying on the bottom of the dresser, andStaff personal belongings were stored in Resident 95's room. These failures could have resulted in the residents not experiencing a clean and well-maintained homelike environment. Findgings: 1. [...]

Inspectors wroteFindings: Based on observation, interview and record review, the facility failed to ensure that three of 46 sampled residents (Resident 7, Resident 39, and Resident 89) had an accurate Minimum Data Set (MDS - a federally mandated resident assessment tool) completed when: 1. Resident 7's MDS was coded as not receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) services while receiving dialysis three times per week, 2. Resident 39's decreased range of motion (ROM) from contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in his right shoulder, right arm, and right hand were coded as having no impairment,3. Resident 89's use of oxygen was coded as not in use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 46 sampled residents (Resident 1 and Resident 8) had properly completed Preadmission Screening and Resident Review (PASRR: required screening done before admission to identify mental illness, intellectual disability, or related conditions and ensure proper placement and services) and received required PASRR Level II (a more detailed evaluation completed when a resident is suspected of having mental illness or intellectual disability to determine needed specialized services) evaluation when;1. Resident 1's diagnosis of developmental disorder of scholastic skills (difficulty learning skills such as reading, writing, or understanding information) was not marked on Resident 1's PASRR screening, 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that oxygen and nebulizer breathing treatment tubing were changed, stored and kept off the floor for 4 of 31 residents (Resident 54, Resident 89, Resident 97, and Resident 115) whom received oxygen therapy when:1. Resident 54's oxygen tubing was not stored in a protective bag and was not labeled with the date of first use;2. Resident 89's oxygen tubing was not stored in a protective bag and had a date of first use of 1/19/26;3. Resident 97's oxygen tubing was not stored in a protective bag, was undated, and was lying on the floor; and4. Resident 115's breathing treatment tubing was not stored in a protective bag and was not labeled with the date of first use. These failures placed Resident 54, Resident 89, Resident 97, and Resident 115 at risk for pulmonary (lung) infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:Two pans that were worn were not replaced; andA rusted scraper was stored with clean utensils in a drawerThese failures had the potential to lead to cross contamination and food borne illness (nausea, vomiting, diarrhea) for a facility census of 94 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to practice appropriate infection prevention and control measures for 3 of 46 sampled residents (Resident 103 and Resident 127, and Resident 128) when1. Resident 103 had unlabeled perishable food (food that can spoil or go bad if not stored properly) on the bedside table; and2. Residents 128 and Resident 127 was observed without the required Enhanced Barrier Precaution signage posted at the door. These failures could result in food borne illnesses for Resident 103 and increased risk of transmission of multidrug-resistant organisms (germs that are very hard to kill because many antibiotics don't work on them) or other infectious pathogens (germs that can cause disease) to Residents 128 and 127, other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident with dignity and respect by not honoring her preferred form of address for 1 of 46 sampled residents (Resident 95), when CNA 1 addressed Resident 95 as Honey. This deficient practice had the potential to negatively affect Resident 95's dignity and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a federally required comprehensive assessment (an in-depth, interdisciplinary evaluation of a resident's physical, functional, psychosocial, and cognitive status, typically conducted upon admission and after significant changes in condition) was completed within the required timeframe for two (2) of 46 sampled residents (Resident 18 and Resident 54) when:1. Resident 18's required Minimum Data Set (MDS -a federally mandated, standardized, and comprehensive assessment tool used in long term care facilities to evaluate a resident's functional, medical, and psychosocial status) annual assessment was not completed within the required 14 days of the assessment reference date (ARD - the specific endpoint of the observation or look back period, serving as the common reference point for assessing a resident's status ).2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three (3) of 46 sampled residents (Resident 2, Resident 7, and Resident 54) were kept free from the potential for injury when,1. A regular bed mattress was stored upright against the wall in Resident 2's room,2. Resident 54's order for floor pads next to both sides of the bed was not followed,3. room [ROOM NUMBER] had a metal strip, 6 inches in length and 1/4 inch in width, noted to be protruding at knee height out of the wall in a loop type fashion (coming out of the wall at top and back into the wall at the bottom) next to the bathroom door near Resident 7's bed. These failures placed Resident 2, Resident 7 and Resident 54 at increased risk for sustaining an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and obtain a physician's order for the safe use of bed rails (side rails, metal or plastic rails that can attached to the side of a bed) for 1 of 46 sampled residents (Resident 1) when, Resident 1's side rail screening tool (an assessment used to decide if bed rails are safe and needed for a resident) was completed incorrectly and Resident 1 did not have a physician's order to ensure side rails were clinically appropriate and safe. This failure placed Resident 1 at risk for entrapment (an event in which an individual is caught, trapped or entangled in the space) and could have led to serious injury.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of 46 sampled residents (Resident 3) prescribed psychotropic drugs (drugs that affect a person's mind, emotions, and behavior) was free from unnecessary medications when Resident 3's as needed (PRN) order for alprazolam (used for short term relief of anxiety, by calming the nervous system) did not have a stop date. This failure had the potential to negatively affect Resident 3's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled to meet professional standards of practice for one of four medication carts when:1. One of four medication carts, Cart 4, contained three insulin pens (a medication dispensing device that help deliver medicine to lower blood sugar) and one insulin vial (a small container of medication) without open dates; and2. One of four medication carts, Cart 4, contained loose pills in the medication drawers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and a safe environment was provided to prevent an elopement (a resident leaves the facility or a secured area without staff permission or knowledge, putting them at severe risk of injury, getting lost, or death from exposure, traffic, or missed medical care) from occurring for one of two sampled residents (Resident 1) when, Resident 1, with severe cognitive impairment (a condition that affects a person's ability to think clearly, remember information, and make safe decisions) and known wandering risk, eloped from the facility during the night on 12/16/25 through an unlocked and unalarmed door located in the facilities laundry room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer or discharge requirements were met for one sampled resident (Resident 1) when, the facility issued a 30-Day Notice of Discharge/Eviction to Resident 1 and Resident 1's Responsible Party (RP) for a denial of payment for services while an application for Medi-Cal (a public health insurance program which provides needed health care services for low-income people) was pending. This failure had the potential to negatively impact Resident 1's psychosocial well-being due to being given the 30-Day Notice of Discharge/Eviction.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of twenty-three sampled residents (Resident 596) received quality care when, Resident 596, who was diabetic (inability for the body to regulate blood sugar/glucose levels) and received insulin (injectable medication used to control/regulate blood sugar/glucose levels) and oral anti-diabetic medications; 1. Experienced injuries from an unwitnessed fall resulting from low blood sugar levels on 9/20/24, 2. Exhibited signs of confusion and altered level of consciousness (a change in a person's state of awareness) and a licensed nurse did not implement emergent nursing interventions to assess Resident 596's blood glucose (BG) level on 9/20/24, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service and safety when: 1. Dietary Aide (DA) 1 was not wearing a hair net while in the kitchen, 2. Drinking glasses and food containers were wet nested (stacked wet promoting growth of bacteria), 3. Clean fruit cups, stored under the dishwasher, had water dripping onto them, 4. Expired yogurt was available for resident consumption, 5. Dishwasher water temperature was not in range, 6. Parts per million (PPM - amount of solution in water) of the dishwashing solution was below the accepted standard, 7. Two of three utensil drawers contained a moderate amount of dust and debris, 8. Two dented cans of corn were found in food storage; available for resident consumption, 9. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the safe use of insulin (a high-risk injectable medication used to treat diabetes, a blood sugar disease) for two residents with diabetes (Resident 1 and Resident 596) out of a sample of 23 residents, when: 1. Resident 1's order for insulin did not include parameters with instruction when blood sugar was high, and ongoing high blood sugar levels were not treated or reported to the medical doctor; and, 2. Resident 596's diabetic medication and insulin use was not monitored by blood sugar measurement. These failures may have contributed to unsafe insulin and antidiabetic drug use and subsequent adverse events.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an anti-anxiety medication was administered correctly for 1 of 23 sampled residents (Resident 61) when Resident 61 received a lower dose of anxiety medication 18 times in May of 2024 and once in September of 2024. This failure had the potential for Resident 61 to experience increased anxiety and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to provide documented evidence of education for immunizations when four of four sampled residents' (Resident 14, Resident 17, Resident 20, and Resident 42) and one unsampled resident's (Resident 23) clinical records did not contain documented evidence of education for the COVID-19 vaccination. This failure had the potential for Resident 14, Resident 17, Resident 20, Resident 42, and Resident 23 to not be aware or informed of the benefits, risks, and potential side-effects of the COVID-19 vaccination prior to receiving or declining the vaccination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for 2 of 23 sampled residents (Resident 382 and Resident 3) when: 1. Resident 382's floor tiles were replaced with a rubber strip; and, 2. Resident 3 had broken blinds in her room. This failure had the potential to negatively impact Resident 382 and Resident 3's feelings of well-being in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop baseline care plans (captures key resident needs and must be developed within 48 hours of admission) for 2 of 23 sampled residents (Resident 545 and Resident 596) when: 1. A baseline care plan was not developed for Resident 545's right groin redness, left groin redness and perirectal (affecting the skin around the rectum) area redness within 48 hours of Resident 545's admission; and, 2. A diabetic (blood sugar disease) baseline care plan was not developed for Resident 596's plan of care to address management, treatment, and monitoring of her diagnosis of diabetes and multiple diabetic medications including insulin (a drug given as shot to treat blood sugar) and oral antidiabetic medications. [...]

Inspectors wroteBased on interview, and record review, the attending physician (AP) failed to provide orders for routine blood glucose (sugar) monitoring and provide adequate physician oversight and management for diabetic (blood sugar disease) care for one of twenty-three sampled residents (Resident 596) when, Resident 596 who was diabetic and received multiple medications to treat her diabetes did not have orders for routine blood sugar monitoring and did not have orders to manage complications associated with her anti-diabetic medication administration and diabetic diagnosis and care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in medication carts (a mobile cart storing medications to be administered to residents) for a census of 93 when: 1. Medication Cart #4 at the facility's South station stored an outdated Lantus insulin Pen (blood sugar drug in a pen form) with an open date (the date the insulin was out of refrigerator and was started to be used) of [DATE] and the pharmacy label indicated discard 28 days after opening; and, 2. The treatment cart at the facility's North station stored an opened bottle of Sterile Sodium Chloride [a mixture of salt and water that is free from bacteria which is used to rinse sinuses, clean wounds, flush eyes and more] in the cart. These failed practices may result in residents receiving expired or unusable medications.

Inspectors wroteBased on interview, and record review, the facility failed to provide documented evidence of education for immunizations (a process by which a person becomes protected against a disease through vaccination) when: 1. One of four sampled residents' (Resident 14) and one unsampled resident (Resident 23) records did not indicate education was provided for the Influenza (a common, sometimes deadly viral infection of the nose, throat and lungs, also called flu) vaccine; and, 2. One unsampled resident's (Resident 23) record did not indicate education was provided for the Pneumococcal Polysaccharide (PPSV 23 - for prevention of pneumonia; an infection that affects one or both lungs) vaccine. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy and standards of practice for medication administration for three of four sampled residents, (Resident 1, Resident 2, and Resident 3) when: 1. Licensed Nurse (LN) 2, failed to sign off medications at the time of administration for Resident 1, Resident 2, and Resident 3; 2. LN 6 administered morning medications late to Resident 1 on 3/7/24; and, 3. LN 4 left the medication cart unattended with medications on top. These failures had the potential for Resident 1, Resident 2, and Resident 3 to receive a duplication of their medications, for Resident 1 to experience health effects from late medications, and for a resident to inadvertently take medications left out on the cart.

Inspectors wroteBased on interview and record review the facility failed to readmit Resident 1 after he transferred to an acute care hospital and was ready to return to the facility. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility.

Inspectors wroteBased on interview and record review the facility failed to consistently schedule and document quarterly Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care), care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents plan of care) for three of three sampled residents (Resident 1, Resident 2, and Resident 3). These failures had the potential for unmet care needs for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident needs were met when: 1. Staff did not respond in a timely manner to calls for help for 5 of 13 sampled residents (Resident 2, Resident 3, Resident 5, Resident 7, and Resident 13); and, 2. The nursing call light system was not fully functional for rooms 28-53 (South Hall) and 45 of 47 residents were not provided an alternate audible method to call staff for help. These failures resulted in Resident 7 not receiving the assistance needed after she fell on 9/2/23 and 9/5/23, and Resident 2, Resident 3, Resident 5, and Resident 13 waiting up to three hours for assistance, with a potential to experience anxiety and feelings of neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment when safe water temperatures were not maintained in five of five sampled resident restrooms, and two out of four resident shower rooms. This failure had the potential to cause physical harm to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 2 of 12 residents receiving respiratory treatment (Resident 22 and Resident 65) when: 1. Oxygen therapy was provided without a physician order for Resident 22; and, 2. Resident 65's oxygen order was not followed. These failures placed Resident 22 and Resident 65 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure doctor's progress notes (doctor's note about resident progress, care, and medical issues) and/or History and Physical (or H&P - the most formal and complete assessment of the resident's medical problems) were documented and available in the medical records for 3 of 25 sampled residents (Resident 23, Resident 27, and Resident 45). These failed practices may contribute to unsafe care and poor communication, or coordination of care among staff members caring for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production when: 1. Open food packages (1 bag of bread rolls, and a box of fried chicken breast patties) were not labeled with an open date; and, 2. An expired food product (an open bag of carrot cake mix) was not removed. These failures had the potential to expose 96 residents of a census of 97 to food borne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to maintain its Antibiotic Stewardship Program (ASP- efforts to measure and improve how antibiotics prescribed by doctors and used by patients with goal of reducing inappropriate antibiotic use) when the facility did not ensure appropriate monitoring and use of antibiotics for 3 of 17 residents who were on antibiotics (Resident 27, Resident 40, and Resident 69) when: 1. Resident 27 was prescribed two antimicrobials (drugs that treat infections caused by microbes like bacteria, yeast, or mold) for ongoing use without any documentation of continued use and re-assessment. 2. Resident 40 was prescribed an antibiotic for ongoing use without any documentation of continued use or re-assessment. 3. Resident 69 was prescribed an antibiotic for ongoing use to which the bacteria was resistant. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was within reach for 1 of 25 sampled residents (Resident 64). This failure had the potential to result in Resident 64 being unable to ask for needed assistance and to negatively impact his physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 25 sampled resident's (Resident 396) right to self-determination was respected when, Resident 396 and Family Member (FM) 1 requested a female Certified Nursing Assistant (CNA) as a care giver and staff did not honor Resident 396's wishes. This failure had the potential to negatively impact Resident 396's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 25 sampled residents (Resident 16), had a care plan (a formal process that correctly identifies existing needs and recognizes potential needs or risks) developed to address Resident 16's arteriovenous fistula (AV- connection between an artery and a vein used as an access site for dialysis, a procedure to remove wastes and excess fluids from the body when the kidneys stop working properly.) This failure had the potential for Resident 16's fistula to be unattended and could possibly lead to complications and risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe monitoring practices for high-risk medication (drugs with potential to cause harm without monitoring) use in 2 out of 25 sampled residents (Resident 60 and Resident 390) when: 1. Resident 60 was prescribed a high-risk blood thinner medication called apixaban (or Eliquis, a blood thinner medication that could cause bleeding) without side effect monitoring and assessment; and, 2. Resident 390 was prescribed a high-risk medication called digoxin (used to control heart rate and rhythm) without any monitoring parameter or care planning. These failures had the potential to result in unsafe medication use and adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body when the kidneys stop working properly) received quality care and services consistent with professional standards of practice for one of three residents (Resident 16), when Resident 16's arteriovenous fistula (AV- connection between an artery and a vein used as an access site for dialysis) was not assessed and monitored regularly for bruit (a sound heard through a stethoscope) and/or thrill (vibrations felt by touch). This failure increased the potential risk for delayed detection, reporting, and/or management of complications from the dialysis access site for Resident 16.

Inspectors wroteBased on interview and record review the facility failed to ensure safe disposal and destruction of the non-narcotic (not an opioid drug) prescription medications for a census of 97. This failed practice could result in drug diversion or unsafe and unlawful use of prescription medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident's in a sample of 25 (Resident 140) nutritional needs were met when the facility did not provide a mechanically soft diet (food chopped for easier chewing and swallowing). This failure had the potential for Resident 140 to aspirate (choke on food) her food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 resident in a sample of 25 (Resident 140) food preferences were honored when Resident 140's food preferences were not listed on her tray card (a card that displays the resident's name, food preferences, likes and dislikes, and meal type and consistency). This failure had the potential for Resident 140 to eat less of her meals and result in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection control program when licensed nurse (LN) 1 did not don(put on) personal protective equipment (PPE - worn to protect against bacteria and viruses) correctly prior to entering the room of a COVID-19 positive resident. This failure had the potential for LN 1 to become infected with COVID 19 and transmitting COVID 19 to other residents in her care.