North Park Nursing Center

In the surveyor’s words

From the most serious findings on record at North Park Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 29, 2024

  Based on interview and record review, the facility failed to ensure a resident without diabetes was free from a significant medication error for 1 of 1 resident reviewed for significant medication errors. (Resident L) This deficient practice resulted in Resident L receiving an overdose of rapid-acting and long-acting insulins and a significant change in condition that required emergent, intensive care at an acute care hospital for treatment of low blood sugar. Finding includes: On 8/22/24 at 2:40 P.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. […]

• Actual harm, isolatedF689May 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and consistent implementation of interventions to prevent falls for 1 of 3 residents reviewed for falls. Resident 31 had a fall that resulted in a fracture to right femur. (Resident 31) Finding includes: During an interview on 5/21/23 at 11:14 A.M., Resident 31's spouse indicated Resident 31 had fallen several times and recently had a fall that resulted in sutures and staples. He was concerned that the falls resulted from a lack of staffing on the unit. He indicated he had been to management several times with the concern, and was told that Resident 31's falls could have been prevented if there was more staff. […]

• No harm, potential for more than minimal, patternF761Aug 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure that medications were properly stored and labeled in 2 of 6 medication carts and 2 of 2 treatment carts observed. (E-Hall, F-Hall, Short Hall Cottage Treatment Cart, A-Hall Treatment Cart) Findings include: 1. On 8/21/24 at 8:50 A.M., the following loose pill was observed in the E-Hall Medication Cart for rooms 141-147: 1/2 small round white pill 2. On 8/21/24 at 8:55 A.M., the following loose pills and unlabeled medications were observed in the E-Hall Medication Cart for rooms 131-140: 2 1/2 small round white pills 1 bottle of Honey Robitussin (cough medicine) with [Resident 33] on bottle but no label or open date 3. […]

• No harm, potential for more than minimal, patternF804Aug 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (A-Hall) Finding includes: On 8/21/24 at 10:06 A.M., Resident Q indicated the food was always cold. On 8/21/24 at 10:44 A.M., Resident 36 indicated the food was usually cold. On 8/21/24 at 2:20 P.M., Resident 33 indicated the food was cold all the time. On 8/23/24 at 1:06 P.M., a test tray was obtained. Food temperatures for that meal were: chicken 114 F (Fahrenheit) fries 109 F coleslaw 55.5 F mandarin oranges 60 F On 8/29/24 at 8:50 A.M., the Dietary Manager indicated food temperatures should be palatable. […]

• No harm, potential for more than minimal, patternF812Aug 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 1 of 1 kitchens observed. The temperature on the final rinse of the dishwasher did not reach required levels, hairnets did not cover hair, and staff touched food with their bare hands. (Kitchen, [NAME] 10, Dietary Aide 25) Findings include: 1. On 8/21/24 at 8:45 A.M., a dishwasher cycle was observed. The final rinse reached 173 degrees Fahrenheit (F). On 8/21/24 at 10:36 A.M., the Dietary Manager indicated the regulation stated the dishwasher final rinse needed to reach 180 F, but the manufacturer said 175 F was acceptable. A service technician had been called that morning. […]