West Park Care Center LLC

In the surveyor’s words

From the most serious findings on record at West Park Care Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 30, 2022

  Based 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. […]

• Actual harm, isolatedF692Mar 6, 2025

  Based 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… […]

• Actual harm, isolatedF740Mar 6, 2025

  Based 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. […]

• Actual harm, isolatedF689Jun 30, 2022

  Based 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 [CONDITION(S)] and subsequent hospitalization . This affected one (Resident #64) out of seven residents reviewed for falls. The facility census was 74. Findings include Review of the medical record for Resident #64 revealed an admitted [DATE]. Diagnoses included dementia, weakness, spinal stenosis, and depression. […]

• No harm, potential for more than minimal, widespreadF584Jun 30, 2022

  Based 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. Findings include 1. […]