Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Park Nursing Center during CMS and state inspections, most recent first.
Two residents with dementia and high fall risk experienced multiple falls due to the facility's failure to update and implement individualized care plan interventions. One resident was encouraged to participate in dressing despite being fully dependent, resulting in a fall, while another resident fell after refusing to go to bed when a required sensory activity intervention was not provided.
A resident with multiple medical conditions and a history of falls was transferred for weighing by only one CNA, despite the care plan requiring two staff, a gait belt, and a front wheeled walker. The CNA was unaware of the two-person assist requirement, and the weight chair was not properly secured, resulting in the resident falling when the chair moved during the transfer.
A resident admitted with multiple wounds, including deep tissue injuries, did not have immediate physician orders for wound care upon admission. Nursing staff documented the wounds and care plans referenced preventative measures, but actual treatment orders were delayed, contrary to facility policy. Staff interviews revealed mischaracterization of wounds and lack of adherence to required protocols, resulting in a deficiency for not securing timely MD orders.
A resident without diabetes received an insulin overdose due to a medication error at a facility. The error occurred when a QMA prepared insulin for another resident, and an RN unfamiliar with the residents administered it to the wrong person. The facility's policies, which prohibited QMAs from administering insulin and required medications to be prepared for one resident at a time, were not followed.
The facility failed to properly store and label medications in two medication carts and two treatment carts. Observations revealed loose and unlabeled pills, as well as unlabeled medicated items, in various halls. An RN confirmed that medications should be labeled, aligning with the facility's policy.
The facility failed to serve food at palatable temperatures, as residents reported consistently cold meals. A test tray showed food temperatures below the required standards, with chicken at 114°F and fries at 109°F, contrary to the facility's policy and sanitation requirements. The Dietary Manager confirmed the expectation for palatable food temperatures.
The facility's kitchen operations were found deficient due to improper dishwasher temperatures and inadequate hygiene practices. The dishwasher's final rinse did not consistently reach the required 180°F, and staff failed to wear hairnets properly and used bare hands to handle food, contrary to facility policies.
The facility failed to document medication administration for several residents, with numerous instances of missing entries in the MAR. This involved various medications, including insulin and antianxiety drugs, across multiple months. The DON could not explain the missing documentation, suggesting possible staff oversight.
The facility failed to conduct timely care plan conferences for three residents, despite having a policy requiring periodic reviews. Residents with various medical conditions, including hemiplegia and diabetes, did not have documented care plan meetings for extended periods, as confirmed by the Social Services Director.
Unqualified QMAs administered insulin to residents and held doses without proper authorization or notification, violating facility policy. Residents with diabetes mellitus were affected, with insulin administered and held without notifying physicians or nurses. The facility's policy prohibited QMAs from administering injections or performing nursing assessments, yet these actions occurred due to misunderstandings about the scope of practice.
Two residents dependent on staff for ADL care did not receive scheduled showers, with one resident receiving only two showers in June and August and none in July, and another receiving eight showers in June, four in July, and one in August. Both residents were cognitively intact and had care plans indicating a preference for showers twice a week. The facility lacked a specific shower/ADL policy, relying on the Resident Rights policy.
A facility failed to monitor daily weights for a resident with congestive heart failure, as ordered by the physician. The resident, with a history of chronic systolic heart failure and edema, had several undocumented weight measurements in June and July. The DON noted the absence of a unit manager contributed to the oversight, and the Administrator stated that staff were expected to follow physician orders despite the lack of a specific policy.
The facility failed to ensure proper hand hygiene and equipment disinfection during resident care. Two CNAs did not change gloves or sanitize hands after handling soiled items and before touching clean items, and they failed to clean the Hoyer Lift after use. Additionally, an LPN did not clean the blood pressure equipment after use. These actions violated the facility's hand hygiene and standard precautions policies.
The facility failed to post accurate nurse staffing information, as observed during the annual survey. On multiple occasions, the posted sheets did not specify the actual hours worked by licensed and unlicensed nursing staff, contrary to the facility's policy. The Administrator acknowledged the inability to determine shift details from the posted sheets.
Failure to Prevent Falls Due to Inadequate Supervision and Care Plan Implementation
Penalty
Summary
The facility failed to prevent falls for two residents who were identified as being at high risk for accidents. One resident with vascular dementia, muscle weakness, and significant cognitive impairment experienced multiple falls after a decline in health and functional abilities. Despite assessments indicating the resident was dependent for activities of daily living (ADLs), including dressing, the care plan continued to encourage the resident to participate in dressing. This led to a fall when the resident, while being assisted by one staff member, became unsteady and lost balance during care. The care plan was not updated in a timely manner to reflect the resident's increased dependency and fall risk. Another resident with vascular dementia, mobility issues, and a history of repeated falls was also at high risk for accidents. This resident, who used a wheelchair and was dependent for mobility and transfers, experienced multiple falls, including one unwitnessed event. The care plan included interventions for fall prevention, such as providing sensory activities if the resident refused to go to bed after dinner. However, after refusing to go to bed, the resident attempted to transfer independently, resulting in a fall. The intervention to provide a sensory activity or busy box was not in place at the time of the incident, contributing to the fall. Record reviews, staff interviews, and observations confirmed that the facility did not consistently implement or update individualized care plan interventions to address the residents' changing needs and fall risks. The facility's policy required resident-centered fall prevention plans and timely care plan updates after falls, but these measures were not adequately followed for the residents involved.
Failure to Follow Care Plan Results in Resident Fall During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracranial hemorrhage, diabetes mellitus with hyperglycemia, polyneuropathy, and morbid obesity experienced a fall during a transfer for weighing. The resident was assessed as requiring substantial/maximal assistance from two staff members, a gait belt, and a front wheeled walker for all transfers, as documented in the care plan and staff assignment sheet. The care plan also specified that the weight chair should be placed against the wall to prevent it from moving during transfers. Despite these documented requirements, only one CNA assisted the resident during the transfer to the weight chair, and the CNA was unaware that two staff were required for this task. As a result, when the resident stood from the weight chair, the chair moved, causing the resident to sit onto the ground. The incident was documented in the progress notes, and it was confirmed through interviews that the care plan was not followed at the time of the fall.
Failure to Obtain Immediate Physician Orders for Wound Care on Admission
Penalty
Summary
A newly admitted resident with multiple diagnoses, including hemiplegia, dysphagia, COPD, malnutrition, and pressure injuries, was admitted to the facility with existing wounds, including a deep tissue injury (DTI) to the right heel and the bottom of the left foot. Upon admission, the resident was assessed by nursing staff, who documented the presence of a bruise on the right heel, an abrasion on the back, and a previous blister on the left foot. The admission observation report confirmed these skin alterations, and a subsequent wound assessment provided measurements and identified the wounds as pressure-related DTIs. Despite these findings, there was a failure to obtain and implement immediate physician orders for wound care at the time of admission. The clinical record and care plans indicated that preventative and treatment approaches were to be initiated, such as floating heels and using pressure-relieving boots, but the actual physician orders for wound treatment were not obtained until several days after admission. The facility's policy required that any alterations in skin integrity be reported to the physician and that treatment orders be obtained promptly, but this process was not followed for the resident upon admission. Interviews with nursing staff and the DON revealed that the wounds were initially mischaracterized, and the required protocol for new skin events was not initiated at the time of admission. The DON acknowledged that both she and the infection prevention nurse were new and learning at the time, which contributed to the delay in recognizing the need for immediate wound care orders. The facility's policies on wound management and skin integrity were not adhered to, resulting in a deficiency related to the lack of timely physician orders for the resident's wounds upon admission.
Resident Receives Insulin Overdose Due to Medication Error
Penalty
Summary
The facility failed to ensure that a resident without diabetes was free from significant medication errors, resulting in an overdose of insulin. Resident L, who had Alzheimer's disease and no history of diabetes, was mistakenly given rapid-acting and long-acting insulins intended for another resident. This error led to a significant change in the resident's condition, requiring emergency care for severe hypoglycemia. The incident occurred when Qualified Medication Aide (QMA) 8 prepared insulin doses for her hallway, and Registered Nurse (RN) 32, who was unfamiliar with the residents, administered the insulin to Resident L instead of the intended recipient, Resident N. The facility's policy did not allow QMAs to administer insulin, and medications were supposed to be given only by the nurse who prepared them. However, RN 32 administered the insulin prepared by QMA 8, leading to the overdose. The facility's policies, including the QMA Parameters and Scope of Practice and Medication Administration policy, were not followed. These policies required that medications be prepared for one resident at a time and that the five rights of medication administration be observed. The error was compounded by the lack of familiarity of RN 32 with the residents and the improper labeling and handling of insulin pens, which were not used according to the facility's Insulin Pen Administration policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two of six medication carts and two treatment carts. On August 21, 2024, surveyors observed loose and unlabeled pills in the E-Hall Medication Cart for rooms 141-147 and 131-140. Specifically, there was a half small round white pill and two and a half small round white pills, along with a bottle of Honey Robitussin labeled only with a resident's name but lacking a proper label or open date. Additionally, in the Short Hall of the Cottage, a medicated Honey Dressing package was found without a label or open date. Further observations on the same day revealed unlabeled materials in the A-Hall Treatment Cart, including an opened tube of antifungal cream and a bottle of wound cleaner, both associated with specific residents but lacking proper labeling. On August 23, 2024, similar issues were noted with an opened antifungal cream ointment and a bottle of wound cleanser, again without labels. During an interview, RN 37 confirmed that there should be no loose pills and that medications should be labeled. The facility's Medication Storage policy, dated August 2023, was provided by the Administrator, indicating that proper medication storage and labeling are standard practices.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by observations and resident interviews. On multiple occasions, residents reported that their food was consistently cold. A test tray was obtained, and the food temperatures were recorded as follows: chicken at 114°F, fries at 109°F, coleslaw at 55.5°F, and mandarin oranges at 60°F. These temperatures did not meet the facility's policy, which requires hot food to be served at palatable temperatures, nor did they comply with the Retail Food Establishment Sanitation Requirements, which mandate that hot food should be at least 135°F and cold food at 41°F or below. The Dietary Manager acknowledged that food temperatures should be palatable, and the Administrator provided a policy indicating the same requirement.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen, as observed during a survey. The dishwasher's final rinse temperature did not consistently reach the required 180 degrees Fahrenheit, with recorded temperatures ranging from 168 to 178 degrees Fahrenheit throughout August. Despite the manufacturer's claim that 175 degrees Fahrenheit was acceptable, the facility's regulation required a higher temperature. A service technician was called to address the issue, and adjustments were made to the dishwasher's settings. Additionally, staff members were observed not adhering to proper hygiene protocols. Hairnets worn by two dietary staff members did not fully cover their hair, and one staff member was seen handling food with bare hands, specifically when plating sandwich buns. The facility's policies required the use of gloves when handling food and mandated that hairnets cover all hair. These observations indicate a lapse in following established sanitary and hygiene procedures in the kitchen.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure complete documentation of medication administration for five out of six residents reviewed. The Medication Administration Records (MAR) for these residents contained numerous instances where medications were not documented as administered. This lack of documentation was observed across several months and involved various medications, including insulin, antianxiety medications, opioids, and anticoagulants. Resident M's records showed multiple instances where insulin lispro, hydrocodone-acetaminophen, lorazepam, and insulin glargine were not documented as given. Similarly, Resident N's records indicated missing documentation for insulin glargine, insulin aspart, and amlodipine. Resident Q's records also had gaps in documentation for medications such as gabapentin, Xanax, and insulin degludec, among others. The issue extended to Resident 86 and Resident 45, where medications like acetaminophen, memantine, Xanax, and Eliquis were not documented as administered. The Director of Nursing (DON) was unable to provide a clear explanation for the missing documentation, suggesting that medications might have been given but not recorded due to staff oversight. The facility's policy required that medication administration be recorded on the MAR/EMAR after being given, with refusals documented appropriately.
Failure to Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed for three residents, identified as Resident M, Resident N, and Resident Q. Resident M, who has diagnoses including hemiplegia, diabetes mellitus, generalized anxiety disorder, and depression, was found to be cognitively intact and dependent on staff for certain activities. However, there were no documented care plan conferences for Resident M between May 9, 2023, and November 6, 2023. Similarly, Resident N, who is cognitively intact and independent in all activities of daily living, did not have documented care plan meetings between June 23, 2023, and February 5, 2024. Resident Q, with conditions such as hemiplegia and irritable bowel syndrome, also lacked documented care plan conferences between July 25, 2023, and February 5, 2024. The Social Services Director confirmed the absence of documented care plan conferences for these residents during the specified periods. The facility's policy, revised in August 2023, requires care plan reviews to be conducted face-to-face, via phone, video conference, or through written communication, based on resident preference. These reviews are to be conducted periodically and following each Minimum Data Set (MDS) assessment. Despite this policy, the facility did not adhere to the required schedule for care plan conferences, leading to the identified deficiency.
Unqualified Staff Administering Insulin
Penalty
Summary
The facility failed to ensure that staff administering insulin to residents were qualified, resulting in unqualified Qualified Medication Aides (QMAs) administering insulin and making decisions about holding insulin without proper authorization or notification. Specifically, QMAs who were not insulin certified administered insulin to three residents, identified as Resident M, Resident N, and Resident Q, and held insulin doses without notifying a physician or nursing staff. This occurred despite the facility's policy that QMAs should not administer medication via injection or perform nursing assessments. Resident M, diagnosed with diabetes mellitus, had insulin administered by QMAs on multiple occasions from February to August 2024. There were instances where insulin was held without notifying a physician or nurse, and no documentation indicated that a nurse assessed the resident. Similarly, Resident N, also diagnosed with diabetes mellitus, had insulin administered and held by QMAs without proper notification or documentation. Resident Q experienced similar issues, with insulin being held on several occasions without physician notification or nurse assessment. The facility's policy explicitly stated that QMAs should not administer medication by injection or perform nursing assessments, yet this was not adhered to. Interviews with facility staff revealed a misunderstanding of the scope of practice for QMAs, with some believing they could administer insulin if a nurse was present. The Director of Nursing acknowledged the need for further education on insulin administration, emphasizing that QMAs should not assess or hold insulin and should document any nurse consultations clearly.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents dependent on staff for activities of daily living (ADL) were adequately showered, as evidenced by the cases of two residents. Resident 33, who was cognitively intact and required substantial to maximal assistance for bathing, reported not receiving showers and only being given bed baths, which left her feeling unclean. Her care plan indicated she should be offered showers twice a week, with partial bed baths in between, and her preferences showed she was most accustomed to showers. However, records revealed that she received only two showers in June, none in July, and two in August, despite being scheduled for showers twice a week. Similarly, Resident Q, who was also cognitively intact and required partial to moderate assistance for bathing, reported infrequent showers, stating she was supposed to receive them twice a week but was lucky to be cleaned once a week. Her care plan also indicated a preference for showers twice a week, with partial baths in between, and she preferred evening showers. Records showed she received eight showers in June, four in July, and only one in August. The facility lacked a specific shower/ADL policy, relying instead on the Resident Rights policy, which emphasizes dignity and self-determination.
Failure to Monitor Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to conduct thorough assessments for a resident receiving a diuretic for congestive heart failure, as daily weights were not obtained as ordered. The resident, who had diagnoses including chronic systolic heart failure, localized edema, and primary pulmonary hypertension, was supposed to have daily weights monitored to manage their condition. However, there were multiple dates in June and July where weights were not documented, and the clinical record did not contain any refusals for these dates. The Director of Nursing acknowledged that there was no unit manager at the time, which led to the weights being missed for various reasons. The Administrator confirmed that while there was no specific policy for following physician orders, it was expected that staff adhere to them. The lack of documentation and monitoring of the resident's weight, as per the physician's orders, constituted a deficiency in the care provided.
Inadequate Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper hand hygiene and equipment disinfection during resident care, as observed in two separate instances involving Resident 9. In the first instance, two CNAs were observed performing peri care for Resident 9 without adhering to proper hand hygiene protocols. CNA 18 and CNA 4 did not change gloves or sanitize hands after handling soiled items and before touching clean items, such as clothing and equipment. Additionally, the CNAs failed to clean the Hoyer Lift after use, leaving it in the hallway without disinfection. In the second instance, an LPN took Resident 9's blood pressure and placed the equipment back on the medication cart without cleaning it. These actions were contrary to the facility's hand hygiene and standard precautions policies, which require hand sanitization before and after glove use and cleaning of shared equipment between residents. The facility's Clinical Support confirmed the expectations for hand hygiene and equipment cleaning during an interview.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information for licensed and unlicensed nursing staff responsible for resident care during the annual survey period. Observations on specific dates revealed discrepancies in the posted nurse staffing data sheets. For instance, on 8/23/24, the sheet indicated that 9.5 unlicensed nursing staff worked the day shift but did not specify which half of the shift they worked. Similarly, on 8/26/24, the sheet showed that 5.5 licensed nursing staff worked the day shift without specifying the shift details. The Administrator provided copies of the posted nurse staffing sheets for several dates, which did not reflect the actual hours worked. The Administrator admitted an inability to determine which half of the shift was worked based on the posted sheets. The facility's policy, revised in 7/2023, requires posting the total number and actual hours worked by nursing staff at the beginning of each shift, which was not adhered to, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Heritage Center | 0.5 mi | ★★★★★ | 0 | 0 |
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| Brickyard Healthcare - Woodbridge Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Columbia Healthcare Center | 1.7 mi | ★★★★★ | 9 | 0 |
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