West Park Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Jun 12, 2023

  Based on review of facility documentation, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to develop a plan of care for a cognitively impaired female resident who was seeking attention from others, especially men. This failure resulted in Resident R114 engaging in inappropriate sexual contact with a male resident placing Resident R114 and other residents in an Immediate Jeopardy situation. Findings Include: Review of facility policy Comprehensive Care Plans revised October 2015 revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the residents related to clinical diagnosis or identified concerns. […]

• Actual harm, isolatedF689Jan 8, 2026

  Based 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).Findings included: Review of facility policy titled Assistive Devices and Equipment revised May 2025, revealed devices and equipment that assist with resident mobility, safety and independence are provided to resident. These include a). wheelchairs (manual and powered) b). walkers and c). […]

• Actual harm, isolatedF600Sep 30, 2024

  Based 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. […]

• Actual harm, isolatedF689Sep 30, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF908Aug 9, 2022

  Based on observations and interviews with staff, it was determined that the facility failed to maintain essential mechanical and food service equipment in safe operational order for use in the Food and Nutrition Department. Findings include: Observation of the main kitchen at 10:30 a,.m., on August 3, 2022 in the presence of the director of dietary services, Employee E16, revealed that the facility lacked the necessary equipment to operate the main kitchen and Food and Nutrition Department to ensure food safety and palatability of foods and beverages served. The main kitchen lacked the ability to steam or convection cook large volumes of foods. Dietary staff were observed using one gas oven and a stove top with four burners. […]