West Park Rehabilitation and Nursing Center

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatment to for pressure ulcer was obtained for

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents with a feeding tube (Resident R2) and for one resident with airborne precautions. (Residents R2 and R3).

Inspectors wroteBased on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain the Resident call bell system in working condition for two out of 10 residents' rooms observed for call bell functioning. Findings Include:On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:53 a.m., observations in room [ROOM NUMBER], Bed D, revealed the call bell device was non-functioning. Resident R2 of room [ROOM NUMBER], Bed D, stated that the call bell was not functioning for a few days. On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:57 a.m., observations in room [ROOM NUMBER], Bed B, revealed the call bell device was non-functioning.

Inspectors wroteBased on staff interviews, review of clinical records, facility documentation, and review of facility policy, it was determined the facility failed to ensure Resident R1 was provided with the necessary equipment of wheelchair leg rest to ensure safety and proper positioning during transportation. This failure resulted in actual harm to Resident R1 who fell forward from the wheelchair and sustained a left frontal scalp hematoma and periorbital contusion for one of nine residents reviewed (Resident R1).

Inspectors wroteBased on clinical record and care plan reviews, observations of residents, policy and procedure review and interviews with staff and residents, it was determined that the facility failed to review and revise the residents care plan for three of 28 residents reviewed, in a timely manner, to ensure the greatest benefit to each resident for safety needs, hospice care, and oxygen use Residents (R4, R7, and R28)

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure physician orderes were followed for one of six residents reviewed for nutrition (Resident 110).

Inspectors wroteBased on observations, interview with resident and staff as well as review of clinical record and review of facility policy, it was determined that facility did not ensure to provide appropriate treatment and services to increase range of motion and/or to prevent further decline for one of 28 residents reviewed (Resident R118)Review of facility policy Resident mobility and range of motion, revised on January 2025, indicates that residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion (ROM). Further review of policy indicates that residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. [...]

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to administer pain medication in accordance with physician orders for one of three residents reviewed for pain management (Residents R84).

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of three residents sampled for behavior. (Resident R45)

Inspectors wroteBased on observations of resident care and services, interviews with staff and residents, clinical record and policy and procedure reviews, it was determined that for one of eight residents reviewed for nutritional needs and support with eating, the facility failed to assist each resident with obtaining routine dental care in a timely manner. (Resident R15)

Inspectors wroteBased on review of facility provided documentation, review of closed record and interview with staff, it was determined facility did not convey the discharge summary to the continuing care provider at the time of discharge and did not contain required components for one of two closed records reviewed (Resident R2)

Inspectors wroteBased on review of clinical record, review of facility policy and interview with staff, it was determined facility did not develop and implement a base line care plan for one of eight residents reviewed related to tracheostomy care and epilepsy. (Resident R1)

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures.

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of six residents reviewed for medication safety (Resident R118).

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for one of three nursing units. (4th [NAME] Nursing Units).

Inspectors wroteBased on clinical record review, observations, and interview with residents and staff, it was determined that the facility failed to provide bathing support and feeding assistance for two of two residents sampled for activities of daily living (Resident R39 and Resident R73). Findings Include: Observation of the Resident R73 on February 18, 2025, at 1:00 p.m. revealed that the resident had beard and disheveled hair. Interview with Resident R73 on February 18, 2025, at 1:00 p.m. stated he wanted to shave and cut his hair, but staff did not offer him any help. Resident stated staff sometimes gave him bed bath but very rarely offered shower. Review of MDS-Minimum Data Set-Assessment of resident care needs for Resident R73 dated November 26, 2024, revealed that the resident had a BIMS score of 15 which indicated that the resident's cognitive status was intact. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that prescribed wound care treatments were not left at the bedside for one of 31 residents reviewed. (Resident R60)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to provide appropriate respiratory care services related to changing and labelling respiratory equipment's and administering oxygen as ordered by the physician for one of 31 residents reviewed. (Resident R19). Findings Include: Review of the facility policy Nebulizer Administration, dated January 2025 revealed that Rinse nebulizer, mouthpiece, and T piece with tap water and let air dry. a. Date and place supplies in a treatment bag. b. Replace and date the setup every seven days. c. Check compressor for air filters that require replacement and cleaning every 30 days. d. Follow manufacturer's instructions. e. Disinfect the outside of the compressor between use of Elders/residents/guests and as needed. [...]

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for two of five residents reviewed (Resident R118 and R104). Findings Include: Review of physician order for Resident R104 dated July 30, 2024 revealed an order for Nifedipine(antihypertensive medication), give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure less than100 or heart rate less than 60 Review of Resident R104's Consultant Pharmacist review report dated December 24, 2024, by consultant pharmacist, revealed a recommendation, Medication error noted. Nifedipine (antihypertensive medication) is not always held as required by the physician's hold order on 12/5, 12/6, 12/9, 12/10, 12/14, 12/15, 12/17, 12/18, 12/19 and 12/20. [...]

Inspectors wroteBased on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of 31 residents reviewed (Resident R83).

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility failed to provide sufficient space for residents for dining services for two of three dining room revealed. (Third floor and Fourth floor)

Inspectors wroteBased on review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that medically-related social services were provided as required for one of 4 residents reviewed (Residents R1).

Inspectors wroteBased on clinical records, incident/accident reports, staff training records, resident and staff interviews and information submitted by the facility, it was determined that the facility failed to ensure that Resident R1 was free from neglect related to not providing the assistance of two staff during a transfer from bed to chair via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a fall, a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1)

Inspectors wroteBased on a review of facility policies, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff and resident interviews, it was determined that the facility failed to ensure resident environment remained as free of accident hazards and failed to ensure that safe techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained a head injury and laceration to the head for one of three residents reviewed. This deficiency was cited as past non-compliance. (Resident R1)

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate discharge notices were provided to the office of the long-term care ombudsman for the following months: January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024.

Inspectors wroteBased on review of clinical records, and interviews with resident and staff, it was determined that the facility did not ensure one resident's rights were exercised related to scheduled dialysis appointments for one of 27 resident records reviewed (Resident R22).

Inspectors wroteBased on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a mid line catheter in accordance with professional standards of practice for one of one resident with midline reviewed (Resident R113).

Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure to administer oxygen therapy in accordance with professional standards of practice related to for two of 28 residents reviewed (Resident R18 and R22).

Inspectors wroteBased on review of facility policy, review of clinical documentation, and interviews with staff, determined the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, by failing to provide dialysis treatment and medication as ordered for one of 34 resident records reviewed (Resident R22).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined the facility did not ensure to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for three of 28 residents reviewed. (Residents R32, R35, and R97)

Inspectors wroteBased on review of facility policies, clinical records and interviews with staff, it was determined that the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included time frames for the different steps in the medication regimen review process and act on irregularities reported by the licensed pharmacist during monthly drug regimen reviews in a timely manner for one of five residents reviewed related to medication regimen reviews (Residents R55).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to offer and/or provide the pneumococcal immunization to two of five residents reviewed (Resident R18 and R33).