West Park Care Center LLC

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policies, the facility failed to ensure residents were provided with adequate bathing to meet resident needs per preferences and schedules. This affected one (#62 of three residents reviewed for activities of daily living (ADLs). The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to obtain resident weight measurements as ordered. This affected one (#76) of four residents reviewed for nutrition. The facility census was 88.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure enteral nutrition products in use were properly marked as ordered and failed to ensure cleaning of a resident's percutaneous endoscopic gastrostomy (PEG) tube site was completed per physician orders. This affected one (#7) of three residents identified by the facility with PEG tubes. The facility census was 88.

Inspectors wroteBased on observation, staff interview, medical record review, and review of a facility policy, the facility failed to administer oxygen to residents at flow rates ordered by prescribers. This affected two (#1 and #69) of two residents reviewed for respiratory care. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff followed established procedures for pharmaceutical service. This affected one (#84) of one residents observed with possession of medications following administration. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure insulin was administered as ordered resulting in a significant medication error. This affected one (#74) of five residents identified by the facility with orders for subcutaneous insulin injections. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview, review of drug manufacturer information, and policy review, the facility failed to ensure medications were properly labeled and dated for storage. This affected three (#46, #77, and #101) of three residents reviewed for medication storage. The census was 88.

Inspectors wroteBased on medical record review, staff interview, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of malnutrition and dehydration, maintained acceptable parameters of nutritional status, failed to initiate appropriate nutritional interventions, and address significant and severe weight loss for Resident #52. This resulted in Actual Harm for one (Resident #52) resident who experienced a significant weight loss of 5.1 percent (%) in four weeks and had ongoing severe weight loss of 13.6% over less than three months, when on 12/10/24 was noted with increased lethargy, malaise and was difficult to arouse, resulting in hospitalization for failure to thrive and percutaneous endoscopic gastrostomy (PEG) tube placement for enteral nutrition support. [...]

Inspectors wroteBased on medical record review, resident guardian interview, staff interview, facility Self-Reported Incident (SRI) review, and review of facility investigation, the facility failed to investigate and implement psychiatric recommendations to ensure Resident #82 had the ability to attain or maintain their highest physical, mental, and psychosocial wellbeing. Actual Harm occurred when the facility failed to fully investigate the root cause of Resident #82's potential hallucinations/behaviors, which contributed to the facility being unable to meet the residents behavioral health needs, resulting in a discharge from the facility. This affected one (Resident #82) of one resident reviewed for behavioral/emotional needs. The facility census was 84.

Inspectors wroteBased on facility financial record review and staff interview, the facility failed to secure a surety bond that covered all of the resident funds. This had the potential to affect 42 residents (#2, #3, #4, #5, #6, #7, #9, #11, #13, #14, #15, #16, #18, #19, #21, #22, #23, #24, #25, #26, #28, #32, #33, #39, #40, #43, #44, #45, #46, #51, #52, #54, #55, #56, #57, #58, #60, #63, #64, #72, #76, #82) of 42 residents who had funds managed by the facility. The census was 84. Findings Include: Review of 42 residents (#2, #3, #4, #5, #6, #7, #9, #11, #13, #14, #15, #16, #18, #19, #21, #22, #23, #24, #25, #26, #28, #32, #33, #39, #40, #43, #44, #45, #46, #51, #52, #54, #55, #56, #57, #58, #60, #63, #64, #72, #76, #82) current financial records revealed the total for all funds managed by the facility was $158,125.48. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure hot water temperatures were maintained below the maximum temperature of 120 degrees. This had the potential to affect 37 residents (#3, #6, #7, #8, #10, #11, #13, #16, #18, #23, #29, #32, #33, #37, #38, #39, #44, #45, #51, #57, #58, #60, #65, #68, #70, #73, #74, #78, #83, #138, #139, #140, #141, #142, #143, #238 and #239) who resided on the [NAME] hallway. In addition, based on medical record review, staff interview, and review of facility policy, the facility failed to ensure Resident #52's fall was documented and investigated. This affected one resident (#52) of ten residents reviewed for accidents. The facility census was 84 residents. Findings Include: 1. a. [...]

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to treat Resident #143 in a dignified manner. This affected one resident (#143) of one resident reviewed for dignity. The facility census was 84.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to notify Resident #140's primary care physician (PCP) of a weight gain outside of the physician ordered parameters. This affected one resident (#140) of five residents reviewed for unnecessary medications. The facility census was 84. Findings Include: Review of the medical record for Resident #140 revealed an initial admission date of 02/18/25 with the diagnoses including light chain (AL) amyloidosis, congestive heart failure, hypertensive heart disease, atrial fibrillation, lymphedema, respiratory syncytial virus (RSV), type one diabetes mellitus, morbid obesity, cardiomyopathy, hyperlipidemia, anemia, chronic kidney disease, hydrocephalus, anxiety disorder, depression, orthopnea, solitary pulmonary nodule, bilateral conductive hearing loss and constipation. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to adequately revise resident care plans. This affected one (Resident #81) of 18 resident care plans reviewed. Findings Include: Review of Resident #81's record revealed she was admitted to the facility on [DATE]. Her diagnoses included complete traumatic amputation between knee and ankle, atrial fibrillation, Crohn's disease, aortic insufficiency, venous insufficiency, hypertension, hyperlipidemia, vitamin D deficiency, other primary thrombophilia, hypokalemia, anxiety disorder, depression, pressure ulcer to right heel (stage II), polyosteoarthritis, edema, and dementia. Review of Resident #81's Minimum Data Set (MDS) assessment, dated 02/04/25, revealed she had a severe cognitive impairment. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure one resident (#140) received routine showers. This affected one resident (#140) out of three residents reviewed for activities of daily living (ADL). The facility census was 84. Findings Include: Review of the medical record for Resident #140 revealed an initial admission date of 02/18/25 with the diagnoses including but not limited to light chain (AL) amyloidosis, congestive heart failure, hypertensive heart disease, atrial fibrillation, lymphedema, respiratory syncytial virus (RSV), type one diabetes mellitus, morbid obesity, cardiomyopathy, hyperlipidemia, anemia, chronic kidney disease, hydrocephalus, anxiety disorder, depression, orthopnea, solitary pulmonary nodule, bilateral conductive hearing loss and constipation. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to complete daily weights as ordered for one resident (Resident #5), failed to implement a physician-ordered fluid restriction for one resident (Resident #140), and failed to ensure lymphedema wraps and interventions were implemented as ordered for one resident (Resident #48). The deficient practices affected three residents (Residents #5, #48, and #140) of 18 reviewed for quality of care. The facility census was 84.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of facility policy and procedure, the facility failed to timely address Resident #143's leaking nephrostomy tube and accurately document the residents hospitalization and subsequent nephrostomy tube replacement. This affected one resident (#143) of one resident reviewed for nephrostomy tubes. The facility census was 84.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure respiratory equipment was stored in a sanitary manner. This affected one resident (#143) of two residents reviewed for respiratory care. The facility census was 84. Findings Include: Review of the medical record for Resident #143 revealed an initial admission date of 02/18/25 with diagnoses including atrial fibrillation, diabetes mellitus, panlobular emphysema, dementia, obstructive and reflux uropathy, artificial openings of urinary tract, hyperlipidemia, hypertension, constipation, acquired absence of other genital organs and urinary tract infection (UTI). Review of Resident #143's admission evaluation dated 02/18/25 revealed the resident was alert and oriented on admission. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to administer medications as ordered, resulting in a medication administration error rate above 5 percent (%). Three errors out of 28 observed opportunities resulted in an error rate of 10.71%. This affected one (Resident #21) of three residents observed during the medication pass. The facility census was 84.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #143's medication was secured in a locked medication cart. This affected one resident (#143) of 18 residents observed for medication storage. The facility census was 84.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure hospice notes were readily available for one resident (Resident #44). This affected one resident (#44) out of one resident reviewed for hospice services. Findings Include: Review of the medical record for Resident #44 revealed an admission date on 04/07/22. Medical diagnoses included frontal lobe and executive function deficit following cerebral infarction, type two diabetes mellitus with diabetic retinopathy without macular edema, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, encounter for palliative care, chronic hepatitis, and syncope and collapse. Review of the hospice contract dated 01/26/24 revealed the contract stated, Communication: [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy the facility failed to ensure staff followed the resident's care plan regarding Hoyer lift transfers. This affected one (Resident #12) of three residents reviewed for Hoyer lift transfers. The census was 86.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure the medical record was accurate related to a change in condition for a resident. This affected one (Resident #1) of three sampled residents. The census was 91.

Inspectors wroteBased on closed medical record review, staff interviews, resident emergency contact interview, review of the hospital history and physical, review of continuity of care, review of hospital ethics team meeting notes, review of a hospital discharge summary, review of a hospital transfer report, review of facility policy related to code status, and review of a facility policy related to Cardiopulmonary Resuscitation (CPR), the facility failed to initiate CPR and contact Emergency Medical Services (EMS) for one resident (Resident #73) who was a Full Code status and was found unresponsive without vital signs. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death, when facility staff did not immediately initiate CPR on Resident #73 nor contact EMS to assist in life-sustaining measures and expired at the facility. [...]

Inspectors wroteBased on medical record review, review of a fall investigation, and staff interviews, the facility failed ensure staff utilized proper precautions while ambulating with residents. Actual harm occurred when State Tested Nurse Aide(STNA) #126 was ambulating with Resident #64, while not using a gait belt, and Resident #64 fell resulting in a left hip fracture and subsequent hospitalization. This affected one (Resident #64) out of seven residents reviewed for falls. The facility census was 74.

Inspectors wroteBased on observations, staff interviews, medical record review, and review of facility policy, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected four residents (Resident #26, #37, #61, and #63) out of 74 residents in the facility. Additionally, the facility failed to maintain an odor free environment in the hallway of the teal unit. This had the potential to affect all 24 residents living on the teal unit (#2, #3, #8, #9, #11, #18, #22, #25, #26, #27, #32, #33, #35, #37, #40, #41, #47, #49, #54, #59, #61, #63, #64, and #67). Additionally, the facility failed to maintain a clean and safe environment in the front of the facility grounds. This had the potential to affect all 74 residents. The facility census was 74.

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to appropriately store and date foods in the refrigerator and freezer. Additionally, the facility failed to appropriately perform hand hygiene during preparation of a lunch meal. This had the potential to affect all 74 residents in the facility. The facility did not have any residents on a nothing by mouth (NPO) diet. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, observations, review of a resident vaccination status list, and facility policy review, the facility failed to properly apply Personal Protective Equipment (PPE) when caring for a resident in isolation, failed to ensure catheter bag tubing was not touching the ground, and failed to implement appropriate isolation precautions while an isolation resident was smoking with other non-isolation residents. This affected five residents (#29, #43, #62, #222, and #223) and had the potential to affect all 74 residents residing in the facility. The facility census was 74.

Inspectors wroteBased on staff interview, medical record review, and review of facility policy, the facility failed to ensure care conferences were held with the interdisciplinary team and resident and/or resident representative. This affected one (Resident #2) out of one resident reviewed for care plan conferences. The facility census was 74.

Inspectors wroteBased on staff interview, medical record review, and review of facility policy, the facility failed to ensure care conferences were held with the interdisciplinary team and resident and/or resident representative. This affected one (Resident #2) out of one resident reviewed for care plan conferences. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure therapeutic diets were provided as ordered. This affected one (Resident #223) out of one resident reviewed for dialysis. The facility census was 74.

Inspectors wroteBased on medical record review, review of pharmacy recommendations, staff interview, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed and a rationale was provided when a pharmacy recommendation was declined. This affected two residents (Residents #2 and #16) out of six reviewed for unnecessary medications and pharmacy recommendations. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, observations, and review of facility policy, the facility failed to ensure that its medication error rate was less than five percent. This affected two (#58 and #17) out of four residents reviewed for medications. There was 25 opportunities with two errors resulting in an eight percent (%) medication error rate. The facility census was 74.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to store medications in a safe and secure manner. This affected three residents (#66, #30, and #2) out of three residents reviewed for medication storage. The facility census was 74.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to obtain labs as ordered by the physician. This affected two (Residents #6 and #16) out of six residents reviewed for routine labs. The facility census was 74.