Deficiencies (last 4 years)
Deficiencies (over 4 years)
28 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
600% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
35 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 19, 2025
Visit Reason
The inspection was conducted due to allegations of resident-to-resident abuse reported by Resident 1 against Resident 2, involving threats and verbal aggression.
Complaint Details
The complaint involved two separate incidents on 11/16/25 and 11/26/25 where Resident 1 alleged Resident 2 threatened and verbally abused her. Resident 1 reported feeling threatened, scared, and unsafe. The facility failed to properly investigate or report these allegations. Resident 1 contacted the state agency. Interviews with staff and residents confirmed the incidents. The Administrator was unaware of the allegations and did not follow required procedures.
Findings
The facility failed to ensure proper identification, reporting, and investigation of abuse allegations made by Resident 1 against Resident 2. The Administrator was unaware of the incidents and did not report or investigate as required, posing a risk of resident-to-resident abuse in a vulnerable population.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Reported the alleged incident from Resident 1 to the Administrator. |
| Administrator | Abuse Coordinator | Was unaware of the abuse allegations and failed to report or investigate as required. |
| DON | Director of Nursing | Interviewed regarding the second incident and aware of Resident 1's report. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 10, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the protection of residents' personal property and to identify deficiencies related to documentation and safeguarding of resident belongings.
Findings
The facility failed to provide reasonable care for the protection of Resident 4's personal property, as the Resident's Clothing and Possessions form was incomplete and unsigned by the resident, potentially risking loss or theft of personal items. Interviews with staff confirmed the documentation deficiencies and acknowledged the findings.
Deficiencies (1)
Resident 4's personal belongings form was not signed by the resident and was not accurately completed, risking loss or theft of personal property.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Verified Resident 4's belongings form was incomplete and unsigned |
| SSD | Social Services Designee | Provided information about Resident 4's account and belongings |
| DON | Director of Nursing | Acknowledged the incomplete and unsigned belongings form |
| Clinical Consultant | Acknowledged the findings of the inspection |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to evaluate compliance with the facility's discharge process policies and procedures, specifically to ensure proper documentation and physician approval for resident discharge.
Findings
The facility failed to ensure that Resident 1's medical record contained physician documentation confirming the resident's health improvement and readiness for discharge, which posed a potential risk for unsafe discharge. The Administrator verified these findings during a telephone interview.
Deficiencies (1)
Failure to ensure Resident 1's medical record showed physician documentation indicating the resident's health improved sufficiently and was ready to be discharged from the facility.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide necessary care and services to two residents, specifically failure to timely arrange an urgent MRI for Resident 85 and failure to document Intake and Output (I&O) for Resident 195 as ordered.
Complaint Details
The investigation was complaint-driven, focusing on two residents. The findings were substantiated with evidence from medical record reviews and staff interviews confirming the failures in communication and documentation.
Findings
The facility failed to ensure Resident 85's Infectious Disease Physician's urgent MRI recommendation was communicated and arranged timely, and failed to document Resident 195's Intake and Output as ordered. These deficiencies had the potential to affect the well-being of both residents.
Deficiencies (2)
Failure to ensure Resident 85's Infectious Disease Physician's recommendation for an urgent MRI of the right hip was communicated to the ordering physician and arranged in a timely manner.
Failure to document Resident 195's Intake and Output (I&O) as ordered every shift for 30 days.
Report Facts
Residents sampled: 35
MRI order date: May 17, 2025
MRI scheduled date: Jul 28, 2025
I&O monitoring duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding Resident 85's MRI scheduling and communication failures |
| SSD | Social Services Director | Interviewed regarding communication about Resident 85's urgent MRI need |
| Case Manager | Interviewed about facility process for scheduling urgent MRIs and communication failures for Resident 85 | |
| LVN 6 | Licensed Vocational Nurse | Interviewed regarding lack of documentation of Resident 195's Intake and Output |
| RN 3 | Registered Nurse | Interviewed regarding Resident 195's I&O documentation failure |
| Medical Records Director | Interviewed regarding lack of documentation of Resident 195's Intake and Output | |
| Administrator | Interviewed and acknowledged findings related to both residents | |
| Administrator Assistant | Interviewed and acknowledged findings related to both residents | |
| DON | Director of Nursing | Interviewed and acknowledged findings related to both residents and nursing documentation responsibilities |
Inspection Report
Routine
Deficiencies: 23
Date: Jul 23, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations, incomplete care plans, medication administration issues, infection control lapses, improper food handling, equipment maintenance problems, and inaccurate resident records.
Deficiencies (23)
Failed to ensure call light was within reach of Resident 63, potentially delaying care.
Failed to maintain a copy of advance directive in Resident 51's medical record.
Failed to ensure non-pharmacological interventions were implemented for Resident 89's depression.
Failed to send notice of discharge to State LTC Ombudsman for Resident 194.
Failed to develop a comprehensive care plan including oxygen administration parameters for Resident 86.
Failed to revise Resident 104's care plan to reflect discontinued breathing treatment order.
Failed to ensure timely communication and scheduling of urgent MRI for Resident 85.
Failed to document Intake and Output for Resident 195 as ordered.
Failed to ensure low air loss mattress settings matched residents' weight for Residents 28, 98, 122, and 131.
Failed to provide appropriate range of motion care and skin assessment for Resident 5 with splints.
Failed to implement floor mats for fall prevention as ordered for Resident 4.
Failed to provide appropriate catheter care and prevent urinary catheter tubing from touching floor for Residents 12, 63, and 89.
Failed to provide safe and appropriate respiratory care including oxygen administration and equipment cleaning for multiple residents.
Failed to ensure dialysis access site was assessed every shift for bruit and thrill for Resident 9.
Failed to administer Resident 9's scheduled medications timely after dialysis appointment and failed to ensure narcotic log signatures.
Failed to ensure proper storage, labeling, and separation of medications and biologicals including expired insulin and unlabeled medications.
Failed to provide Resident 93 with consistent carbohydrate diet as ordered.
Failed to maintain sanitary conditions in kitchen including unclean ice scoop holders, dirty plate cover rack, and worn meal tray covers.
Failed to implement safe food handling policy for foods brought in by visitors and failed to label resident foods properly.
Failed to implement infection control practices including proper linen storage, hand hygiene during wound care, and appropriate isolation signage.
Failed to monitor antibiotic use accurately and address use when resident's condition did not meet infection criteria for Resident 89.
Failed to maintain ice machines in sanitary condition and follow manufacturer cleaning specifications.
Failed to ensure complete and accurate entrapment assessments for residents using bed rails and grab bars.
Report Facts
Residents affected: 35
Episodes of depression: 56
Weight: 134
Weight: 103
Oxygen rate: 6
Oxygen rate max allowed: 5
Medication doses missed: 8
Residents receiving food: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified lack of documentation for Resident 89's catheter care and medication communication |
| LVN 2 | Licensed Vocational Nurse | Verified Resident 89's oxygen administration documentation missing |
| DON | Director of Nursing | Acknowledged multiple findings including oxygen administration, infection control, and medication errors |
| Maintenance Director | Verified ice machine sanitation issues and bed entrapment assessment discrepancies | |
| IP | Infection Preventionist | Verified antibiotic stewardship program deficiencies and outside food policy gaps |
| LVN 8 | Licensed Vocational Nurse | Verified medication administration errors and narcotic log signature omissions |
| RT 1 | Respiratory Therapist | Verified BiPAP cleaning documentation missing |
| LVN 11 | Licensed Vocational Nurse | Observed failing hand hygiene during wound care |
| LVN 3 | Licensed Vocational Nurse | Verified oxygen tubing unlabeled and undated for Resident 80 |
| LVN 9 | Licensed Vocational Nurse | Observed oxygen catheter tubing touching floor for Resident 12 and 162 |
| RN 4 | Registered Nurse | Verified missing narcotic log signatures |
| LVN 10 | Licensed Vocational Nurse | Verified missing narcotic log signatures |
| LVN 7 | Licensed Vocational Nurse | Verified medication storage issues in Medication Room A |
| LVN 1 | Licensed Vocational Nurse | Verified antifungal powder administered without physician order |
| Activities Director | Verified incomplete Resident Council documentation | |
| Social Services Assistant 2 | Verified Resident 49 hoarding food in restroom bathtub without education documentation | |
| Housekeeping Supervisor | Verified soiled laundry stored in clean laundry area |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's provision of pharmaceutical services and ensure medications were administered within prescribed times to residents.
Findings
The facility failed to ensure timely medication administration to 16 sampled residents, with medications not provided within their prescribed times, posing potential negative health outcomes. Observations and interviews confirmed delays in medication administration due to staff attending to residents with changes in condition.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist, resulting in medications not administered within prescribed times to 16 sampled residents.
Report Facts
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Observed and interviewed regarding late medication administration at 0900 hours | |
| LVN 2 | Observed and interviewed regarding late medication administration at 0900 hours | |
| LVN 6 | Observed administering medication to Resident 16 and interviewed about medication timing | |
| DON | Interviewed regarding expectations for timely medication administration and notification of physicians | |
| Assistant Administrator | Informed and acknowledged findings | |
| ADON | Informed and acknowledged findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
The inspection was conducted to investigate the facility's compliance with safe and appropriate administration of IV fluids for residents, specifically focusing on monitoring and recording of fluid intake and output for Resident 1.
Complaint Details
The visit was complaint-related focusing on the failure to monitor and document fluid intake and output for Resident 1 on IV therapy. The deficiency was substantiated with evidence from medical record review and staff interviews.
Findings
The facility failed to ensure that Resident 1's IV and oral fluid intakes were monitored and recorded as required by facility policy, posing a risk of fluid overload and potential harm. Interviews with staff confirmed the lack of documentation for intake and output monitoring despite the resident being on IV therapy.
Deficiencies (1)
Failure to ensure Resident 1's IV and oral fluid intakes were monitored and recorded as per facility policy.
Report Facts
IV fluid infusion rates: 50
IV fluid infusion rates: 110
IV fluid infusion rates: 50
TPN goal nutrients kcal: 1100
TPN goal nutrients kcal: 1300
TPN goal protein grams: 46
TPN goal protein grams: 55
TPN water ml: 2000
Sodium Chloride IV solution rate: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Interviewed and confirmed no daily intake and output documentation for Resident 1 on IV therapy | |
| Administrator | Interviewed and verified lack of documentation for Resident 1's daily intake and output monitoring |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pressure ulcer prevention, infection control, and notification of changes in condition at French Park Care Center.
Findings
The facility was found deficient in timely physician notification of a resident's change in condition, inadequate pressure ulcer care and care planning for residents with wounds, and failure to maintain proper infection control practices including lack of physician orders for contact precautions and improper placement of PPE disposal trash cans.
Deficiencies (3)
Failure to ensure timely physician notification of Resident 6's change in condition, risking inadequate care.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents 4 and 6, including failure to assess and manage pain and develop care plans for wounds.
Failure to maintain infection prevention and control program, including lack of physician order for contact precautions for Resident 5 and absence of trash can for PPE disposal in Room B.
Report Facts
Residents sampled: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
Pressure injury measurement: 1.1
Pressure injury measurement: 0.8
Pressure injury measurement: 0.1
Pressure injury measurement: 9
Pressure injury measurement: 8
Braden Scale score: 14
Braden Scale score: 12
Vital signs: 65
Vital signs: 83
Vital signs: 63
Medication dosage: 40
Medication dosage: 325
Medication dosage: 100
Medication duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Observed wound care treatment and failure to assess pain for Resident 4 |
| CNA 5 | Certified Nursing Assistant | Assisted with wound care and provided incontinence care for Resident 4 |
| DON | Director of Nursing | Interviewed regarding expectations for nurse notification and infection control |
| RN 2 | Registered Nurse | Interviewed about contact precautions for Resident 5 |
| IP | Infection Preventionist | Interviewed regarding infection control deficiencies and policy compliance |
| LVN 3 | Licensed Vocational Nurse | Interviewed about knowledge of contact precautions in Nurse Station A |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was conducted following a complaint alleging the facility failed to timely report a reasonable suspicion of sexual abuse involving Resident 1, which was reported two days late to the appropriate authorities.
Complaint Details
The complaint investigation was substantiated as the facility acknowledged and verified the failure to report the sexual abuse allegation immediately as required by their policies and regulations.
Findings
The facility failed to immediately report an allegation of sexual abuse within two hours as required by policy and regulations, potentially delaying investigation and corrective actions. Additionally, the facility failed to ensure a safe environment by allowing a portable space heater in Resident 4's room, posing a fire hazard.
Deficiencies (2)
Failure to timely report suspected sexual abuse allegation within two hours to CDPH, LTC Ombudsman, and law enforcement.
Failure to ensure a safe environment by allowing a portable space heater in Resident 4's room, posing a fire hazard.
Report Facts
Residents sampled: 3
Residents affected - Few: Sexual abuse reporting deficiency affected one of three sampled residents (Resident 1)
Residents affected - Some: Portable heater safety deficiency affected one of three sampled residents (Resident 4)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged failure to timely report sexual abuse allegation and verified findings | |
| DON | Director of Nursing | Verified facility did not report sexual abuse allegation immediately as per policy |
| RN 1 | Registered Nurse | Interviewed regarding awareness of portable heater in Resident 4's room |
| Maintenance Director | Removed portable heater from Resident 4's room and confirmed facility policy |
Inspection Report
Routine
Deficiencies: 3
Date: May 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, therapeutic leave procedures, infection prevention and control practices, and call light accessibility at French Park Care Center.
Findings
The facility failed to ensure call lights were within reach for residents at high risk of falls, failed to monitor and document therapeutic leave times and assessments for residents, and did not consistently implement enhanced barrier precautions for residents with indwelling medical devices, potentially risking resident safety and infection control.
Deficiencies (3)
Failed to provide reasonable accommodations to ensure call lights were within reach for residents at high risk of falls.
Failed to ensure residents on therapeutic leave did not exceed authorized leave times and failed to document assessments and notify physicians accordingly.
Failed to implement enhanced barrier precautions for residents with indwelling medical devices, including lack of ESP signage and PPE use.
Report Facts
Residents sampled: 12
Residents affected: 2
Residents affected: 2
Residents affected: 3
Maximum therapeutic leave hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding call light accessibility for Resident 12 |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding call light accessibility for Resident 9 |
| DON | Director of Nursing | Interviewed regarding call light policies and therapeutic leave documentation |
| LVN 8 | Licensed Vocational Nurse | Interviewed regarding Resident 1's therapeutic leave compliance |
| Unit Manager 1 | Unit Manager | Verified findings related to therapeutic leave and infection control |
| Unit Manager 3 | Unit Manager | Interviewed regarding Resident 10's therapeutic leave documentation |
| Administrator | Facility Administrator | Verified findings related to therapeutic leave documentation |
| IP | Infection Preventionist | Interviewed regarding enhanced barrier precautions and infection control practices |
| CNA 9 | Certified Nursing Assistant | Observed and interviewed regarding infection control practices for Resident 7 |
| LVN 6 | Licensed Vocational Nurse | Observed regarding infection control practices for Resident 7 |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to food safety, medical record documentation, and infection prevention and control practices at the nursing home.
Findings
The facility was found deficient in multiple areas including improper storage and labeling of foods brought in by visitors, incomplete medical record documentation for a sampled resident, and failures in infection control practices such as inadequate hand hygiene and improper handling of linens.
Deficiencies (3)
Failure to ensure safe and sanitary handling of residents' foods brought in from outside, including unlabeled and improperly stored food items.
Failure to maintain complete and accurate medical records for one sampled resident, including missing documentation of ADL Bed Mobility interventions.
Failure to provide and implement an infection prevention and control program, including staff failing to perform hand hygiene and improper handling of linens.
Report Facts
Missing documentation dates: 15
Number of residents sampled: 8
Number of residents affected: 2
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse 1 | Treatment Nurse | Named in infection control deficiency for failure to perform proper hand hygiene during wound care |
| Treatment Nurse 2 | Treatment Nurse | Named in infection control deficiency and interview regarding hand hygiene practices |
| CNA 3 | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene and improper glove use |
| CNA 5 | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene when leaving an Enhanced Precaution room and touching clean linen with soiled gloves |
| Medical Records Director | Medical Records Director | Verified missing documentation for Resident 1 |
| DSD | Acknowledged missing documentation for Resident 1 | |
| LVN 4 | Licensed Vocational Nurse | Interviewed regarding overflowing soiled linen bin |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding overflowing soiled linen bin |
| RN Supervisor | Registered Nurse Supervisor | Acknowledged findings related to infection control and linen handling |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to promptly notify a resident's family of the resident's transfer and admission to an acute care hospital, and concerns about the accuracy and completeness of the resident's medical records.
Complaint Details
The complaint investigation found that the facility did not promptly notify Resident 1's family of the transfer to the acute care hospital, with notification occurring one day after transfer. The facility also failed to maintain accurate medical records, including missing documentation of medication administration and discrepancies in medical diagnoses.
Findings
The facility failed to promptly notify Resident 1's family of the transfer and admission to the acute care hospital as required by facility policy. Additionally, the facility failed to maintain accurate and complete medical records for Resident 1, including missing documentation of medication administration and discrepancies in medical diagnoses between facility and hospital records.
Deficiencies (2)
Failure to promptly inform the resident's family of transfer and admission to acute care hospital.
Failure to maintain accurate and complete medical records, including missing medication administration documentation and inaccurate medical diagnoses.
Report Facts
Residents sampled: 7
Date of transfer: Apr 9, 2023
Missed medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Interviewed regarding family notification procedures |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding medication administration and medical record accuracy |
| DON | Director of Nursing | Verified findings related to family notification and medical record deficiencies |
| Administrator | Informed and acknowledged findings with DON |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with hand hygiene and use of personal protective equipment (PPE) to prevent disease transmission.
Findings
The facility failed to ensure housekeeping staff performed hand hygiene after removing gloves and gowns in a COVID isolation room, and a CNA failed to wear the appropriate gown while providing care to a resident on enhanced barrier precautions. These lapses posed a risk of infection transmission.
Deficiencies (2)
Housekeeping staff did not perform hand hygiene after removing gloves and gown in a COVID isolation room.
CNA 4 failed to wear the appropriate gown while providing care to Resident 9 on enhanced barrier precautions.
Report Facts
Residents affected: 11
Physician's order date: Jan 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Failed to wear appropriate PPE while assisting Resident 9 |
| DON | Director of Nursing | Provided statements regarding hand hygiene and PPE expectations |
| IP | Infection Preventionist | Provided statements regarding infection control practices and PPE requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide written notification to a resident and/or their representative before changing the resident's room.
Complaint Details
The complaint investigation found that Resident 1 was transferred from Unit A to Unit B on 1/17/24 without written notification to the resident or their representative, despite the facility's policy requiring such notice. Interviews with Family Member 1, RN 1, and the Director of Nursing confirmed the lack of documented notification.
Findings
The facility failed to provide written notice and the reason for a room change to Resident 1 and/or their representative before transferring the resident from Unit A to Unit B. This failure had the potential to prevent the resident and responsible party from receiving necessary information about the room change.
Deficiencies (1)
Failed to provide the resident and/or resident representative written notification before the resident's room was changed, including the reason for the move.
Report Facts
Date of room transfer order: Jan 16, 2024
Date of room transfer: Jan 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified findings that no written notification was provided for room change |
| DON | Director of Nursing | Acknowledged the findings regarding failure to provide written notification |
Inspection Report
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program compliance.
Findings
The facility failed to ensure staff performed hand hygiene between meal tray passes, posing a risk for potential transmission of communicable diseases to residents.
Deficiencies (1)
Failure to ensure staff performed hand hygiene between trays during meal pass observation for Residents 2, A, and B.
Inspection Report
Routine
Deficiencies: 6
Date: Oct 31, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at French Park Care Center.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to ensure call lights were within residents' reach, failure to maintain a safe and homelike environment, failure to protect residents from verbal abuse, failure to initiate baseline care plans timely, and failure to implement an effective infection prevention and control program.
Deficiencies (6)
Failure to assess residents (Residents 58 and 152) for safe self-administration of medications and lack of physician orders and care plans for self-administration.
Failure to ensure call lights for Residents 85, 94, 104, and 109 were within reach, potentially delaying care.
Room C had two blind slats missing from the window, risking privacy and an unkempt environment.
Failure to protect Resident 145 from verbal abuse by Resident 173, with inadequate documentation and delayed room change.
Failure to initiate baseline care plan for psychotropic medication (quetiapine fumarate) for Resident 126 upon admission.
Failure to implement infection prevention and control program including improper hand hygiene by staff, failure to follow novel respiratory precautions, uncovered clean laundry cart, failure to disinfect call lights, failure to offer hand hygiene after meals, and uncovered/unlabeled urinal.
Report Facts
Residents sampled: 35
Residents affected by self-administration deficiency: 2
Residents affected by call light deficiency: 4
Residents affected by verbal abuse issue: 1
Residents affected by baseline care plan deficiency: 1
Residents affected by infection control deficiencies: Some
Infection Surveillance Monthly Report counts July 2023: 14
Infection Surveillance Monthly Report counts July 2023: 23
Infection Surveillance Monthly Report counts August 2023: 29
Infection Surveillance Monthly Report counts August 2023: 29
Infection Surveillance Monthly Report counts September 2023: 15
Infection Surveillance Monthly Report counts September 2023: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 6 | Licensed Vocational Nurse | Verified medications at Resident 58's bedside lacked physician orders for self-administration |
| DON | Director of Nursing | Verified no physician orders or care plans for Resident 58 and Resident 152 self-administration |
| ADON | Assistant Director of Nursing | Verified no physician orders or care plans for Resident 58 and Resident 152 self-administration |
| UM 4 | Utilization Manager | Verified no assessment or physician orders for Resident 152 self-administration |
| CNA 6 | Certified Nursing Assistant | Verified Resident 104's call light was not within reach |
| Maintenance Director | Maintenance Director | Verified missing blind slats in Room C window |
| Resident 145 | Reported verbal abuse by Resident 173 | |
| Resident 173 | Resident involved in verbal abuse incidents | |
| Administrator | Facility Administrator | Acknowledged delayed baseline care plan for Resident 126 |
| RN 3 | Registered Nurse | Verified delayed baseline care plan for Resident 126 |
| CNA 7 | Certified Nursing Assistant | Observed wearing KN95 mask instead of N95 in novel respiratory precaution room |
| RN 2 | Registered Nurse | Confirmed CNA 7 should wear N95 mask in novel respiratory precaution room |
| LVN 7 | Licensed Vocational Nurse | Observed not performing hand hygiene between medication routes and improper glove storage |
| LVN 8 | Licensed Vocational Nurse | Observed not performing hand hygiene between medication routes |
| LVN 4 | Licensed Vocational Nurse | Observed not performing hand hygiene between medication routes |
| Housekeeping Staff 1 | Housekeeping Staff | Observed transporting uncovered clean personal laundry cart |
| Housekeeping Team Lead | Housekeeping Team Lead | Verified clean personal laundry cart should be covered during transport |
| RNA 5 | Resident Nursing Assistant | Did not offer hand hygiene to Resident 145 after meals |
| RNA 2 | Resident Nursing Assistant | Did not offer hand hygiene to Resident 3 after meals |
| RNA 6 | Resident Nursing Assistant | Verified unlabeled, uncovered urinal with urine on Resident 4's siderail |
| IP | Infection Preventionist | Described infection surveillance process and acknowledged gaps in monitoring residents not on antibiotics |
| SSA 2 | Social Services Assistant | Interviewed regarding verbal abuse and room change issues between Residents 145 and 173 |
| UM 1 | Utilization Manager | Interviewed about verbal abuse and room change issues between Residents 145 and 173 |
| ADON | Assistant Director of Nursing | Interviewed about verbal abuse and room change documentation for Residents 145 and 173 |
Inspection Report
Routine
Deficiencies: 28
Date: Oct 31, 2023
Visit Reason
The inspection was a routine survey of French Park Care Center to assess compliance with healthcare regulations including medication management, resident rights, infection control, and safety measures.
Findings
The facility had multiple deficiencies including failure to assess residents for safe self-administration of medications, inadequate call light accessibility, privacy violations, incomplete advance directive documentation, improper medication restraint use, failure to notify ombudsman of transfers, incomplete care plans, poor hospice coordination, nutritional care failures, medication administration errors, infection control lapses, and incomplete entrapment assessments for bed rails.
Deficiencies (28)
Failure to assess residents 58 and 152 for safe self-administration of medications prior to allowing self-administration.
Failure to ensure call lights were within reach for residents 85, 94, 104, and 109.
Failure to maintain resident privacy during care for Resident 109.
Failure to provide a safe, clean, homelike environment due to missing blind slats in Room C.
Failure to protect Resident 145 from verbal abuse by Resident 173.
Failure to ensure physical restraints (mittens) were properly assessed, monitored, and released for Residents 159 and 83.
Failure to notify the LTC Ombudsman of transfers for Residents 66 and 144.
Failure to notify Residents 66 and 144 or their representatives of bed hold rights upon transfer to hospital.
Failure to initiate baseline care plan for quetiapine fumarate medication upon admission for Resident 126.
Failure to develop care plans addressing weight loss for Resident 106 and MASD for Resident 120.
Failure to ensure proper assessment, documentation, and care plan for PICC line use for Resident 527 and midline IV labeling for Resident 177.
Failure to follow physician orders for oxygen therapy and ensure proper oxygen equipment maintenance for Residents 91, 108, 141, and 61.
Failure to coordinate hospice care and maintain complete hospice documentation for Residents 528 and 146.
Failure to provide appropriate nutritional supplementation and notify physician of RD recommendations for Resident 161.
Failure to accurately document narcotic medication administration and secure narcotic disposition bin; narcotic medications not fully diluted.
Failure to perform side effect monitoring specific to psychotropic medications and implement non-pharmacological interventions for Residents 85 and 126.
Failure to monitor seizure activity and side effects of anticonvulsant medication for Resident 85.
Failure to monitor target behaviors and implement gradual dose reductions for psychotropic medications for Residents 85, 106, 120, 123, and 126.
Failure to perform hand hygiene between medication routes and during medication administration for Residents 59, 146, and 160.
Failure to maintain clean and sanitary kitchen utensils, cutting boards, and food scoops.
Failure to properly close four of eight outside garbage dumpsters.
Failure to maintain accurate medical records including incomplete documentation of capacity, clothing possessions, hydration orders, change in condition, and catheter care for Residents 48, 66, and 106.
Failure to implement infection prevention and control program including incomplete infection surveillance, improper hand hygiene, failure to follow novel respiratory precautions, uncovered clean laundry cart, and contaminated call light handling.
Failure to offer pneumococcal vaccine to Resident 106 when eligible per CDC guidelines.
Failure to maintain accurate quality control records for blood glucose monitoring device.
Failure to complete accurate and complete entrapment assessments for bed rails for multiple residents including Residents 38, 79, 104, 123, 142, 146, 161, and 528.
Failure to lock medication cart when unattended, dispose expired medications and supplies, and prevent medication left unattended at bedside for Resident 160.
Failure to follow physician orders for flushing G-tube and medication administration for Resident 146 and failure to provide education and administer probiotic medication for Resident 59.
Report Facts
Medication error rate: 10
Residents affected: 35
Residents affected: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 6 | Verified medications at bedside without physician orders for self-administration | |
| DON | Director of Nursing | Verified multiple findings including medication and infection control deficiencies |
| ADON | Assistant Director of Nursing | Verified multiple findings including medication and infection control deficiencies |
| UM 4 | Verified lack of assessments and care plans for restraints and hospice care | |
| RN 2 | Verified restraint and hospice care deficiencies | |
| SSA 2 | Verified lack of transfer/discharge notices to ombudsman | |
| RD | Registered Dietitian | Verified lack of nutritional care plans and physician notification |
| LVN 4 | Observed medication administration errors and lack of resident education | |
| Pharmacy Consultant 1 | Acknowledged lack of non-pharmacological intervention recommendations | |
| LVN 5 | Verified narcotic medication documentation errors | |
| LVN 7 | Observed hand hygiene lapses and medication administration errors | |
| Maintenance Director | Verified incomplete entrapment assessments | |
| IP | Infection Preventionist | Verified infection control surveillance deficiencies |
Inspection Report
Deficiencies: 2
Date: Oct 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident environment quality and medical record accuracy at French Park Care Center.
Findings
The facility failed to maintain comfortable sound levels for two residents due to loud television noise, and failed to ensure accurate medical record documentation for one resident due to forged activity attendance initials. Both deficiencies had potential for minimal harm.
Deficiencies (2)
Failure to ensure comfortable sound levels for two of 12 sampled residents due to loud television noise disrupting residents.
Failure to ensure accurate medical record documentation for one resident due to forged activity attendance initials by another staff member.
Report Facts
Sampled residents: 12
Residents affected: 2
Residents affected: 1
Dates with forged initials: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant 1 | Named in finding regarding forged activity attendance initials | |
| Activity Director | Interviewed regarding forged initials and investigation initiation | |
| LVN 1 | Licensed Vocational Nurse | Verified loud television noise observations |
| DON | Director of Nursing | Interviewed and acknowledged findings related to noise levels |
| Administrator | Acknowledged findings and stated intention to initiate investigation |
Inspection Report
Routine
Census: 161
Deficiencies: 5
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, staffing adequacy, medication administration, foot care, and facility-wide assessment.
Findings
The facility failed to provide adequate care and assistance for activities of daily living due to insufficient CNA staffing, resulting in residents experiencing delays in care and hygiene. Medication administration errors were noted for two residents. The facility also failed to arrange transportation for a podiatry appointment for one resident. Additionally, the facility did not establish appropriate staffing levels in its facility assessment to meet resident needs.
Deficiencies (5)
Failed to provide necessary care and services to ensure residents maintained good grooming and personal hygiene due to understaffing of CNAs.
Failed to provide appropriate treatment and care according to orders, including failure to administer medications as per physician's orders for two residents.
Failed to arrange transportation to and from podiatry appointments for one resident, risking lack of foot care treatment.
Failed to provide enough nursing staff every day to meet the needs of every resident; inadequate CNA staffing during multiple shifts.
Failed to conduct and document a facility-wide assessment to determine necessary resources and staffing levels based on resident population.
Report Facts
Census: 161
Census: 103
CNA Staffing Required: 21
CNA Staffing Required: 15
CNA Staffing Required: 11
CNA Staffing Actual: 4
CNA Staffing Actual: 6
CNA Staffing Actual: 3
Residents per CNA: 25
Missed Showers: 2
Missed Medications: 8
Missed Medications: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Family Member 1 | Provided interview regarding understaffing and missed podiatry appointment for Resident 1. | |
| Administrator | Facility Administrator | Confirmed staffing challenges, personally provided ADL care on 7/7/23, and verified staffing data. |
| CNA 1 | Certified Nursing Assistant | Interviewed about staffing concerns and inability to provide adequate care. |
| CNA 2 | Certified Nursing Assistant | Interviewed about staffing concerns and inability to follow shower schedule. |
| CNA 3 | Certified Nursing Assistant | Expressed concerns about unsafe staffing and inability to provide essential care. |
| CNA 4 | Certified Nursing Assistant | Reported responsibility for over 20 residents and inability to complete all care tasks. |
| CNA 6 | Certified Nursing Assistant | Reported working alone for 34 residents on 7/8/23 and inability to provide all required care. |
| LVN 1 | Licensed Vocational Nurse | Verified missed showers for Resident 2 and confirmed missed podiatry appointment for Resident 1. |
| DON | Director of Nursing | Verified medication administration errors and missed podiatry appointment; acknowledged importance of foot care and documentation. |
| SSD | Social Services Director | Verified missed podiatry appointment and lack of documented transportation arrangements. |
Inspection Report
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care and prevention protocols following concerns about the facility's failure to provide necessary care and documentation for pressure ulcers in one sampled resident.
Findings
The facility failed to obtain and document measurements and detailed wound descriptions for multiple pressure ulcers on Resident 1, resulting in an inability to monitor the progression of these ulcers. The Director of Nursing confirmed that required skin assessments were incomplete, preventing determination of whether the ulcers worsened.
Deficiencies (1)
Failure to obtain and document measurements and wound descriptions for Resident 1's pressure ulcers, including unstageable ulcers and a Stage 3 ulcer around the tracheostomy site.
Report Facts
Residents Affected: 2
Date of skin evaluation: Jun 6, 2023
Date of survey completion: Jun 14, 2023
Delay in assessment: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and verified findings regarding incomplete skin assessments |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 11, 2023
Visit Reason
The inspection was conducted following a complaint and incident involving Resident 1 who fell off the bed and the facility's failure to implement the IDT's recommendation for two-person assistance during care.
Complaint Details
The visit was complaint-related due to Resident 1's fall and the facility's failure to implement the IDT recommendation for two-person assistance. The complaint was substantiated as the recommendation was not followed or communicated.
Findings
The facility failed to ensure the interdisciplinary team's recommendation for two CNAs to assist Resident 1 during bed care was implemented and communicated, creating a risk for further falls. Interviews and record reviews confirmed the recommendation was not documented in the care plan or communicated effectively to staff.
Deficiencies (1)
Failure to implement and communicate the IDT recommendation for two-person assistance during care for Resident 1 after a fall.
Report Facts
Date of fall: Apr 3, 2023
Date of IDT recommendation: Apr 3, 2023
Date of observation and interviews: Apr 20, 2023
Date of interviews: Apr 21, 2023
Date of DON interview: Apr 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Present during Resident 1's fall and unaware of the IDT recommendation | |
| LVN 1 | Licensed Vocational Nurse | Attended IDT meeting and thought an in-service was held but no documentation found |
| LVN 2 | Licensed Vocational Nurse | Attended IDT meeting and stated verbal communication of recommendation without documentation |
| DON | Director of Nursing | Acknowledged findings and stated care plan should have been updated |
| RN | Registered Nurse | Aware of fall but not aware of IDT recommendation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 24, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident ingesting an antiseptic cleanser left at the bedside, and concerns about medication storage security.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 ingested approximately 5 ml of chlorhexidine gluconate 4% left in a clear drinking cup at the bedside. Resident 1 experienced vomiting and was monitored for adverse effects. The investigation included interviews with involved staff and review of medical records.
Findings
The facility failed to ensure Resident 1 was kept free from accident hazards and received adequate supervision, resulting in ingestion of chlorhexidine gluconate. Additionally, the facility failed to secure medications properly, as a treatment cart containing multiple medications was left unlocked and accessible to residents and visitors.
Deficiencies (2)
Failure to ensure Resident 1 was kept free from accident hazards and received adequate supervision, leading to ingestion of chlorhexidine gluconate antiseptic cleanser.
Failure to ensure drugs and biologicals were stored in locked compartments; Treatment Cart 1 was left unlocked and accessible to residents and visitors.
Report Facts
Amount of chlorhexidine ingested: 5
Date of survey completion: Mar 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Left chlorhexidine solution in a drinking cup at Resident 1's bedside, leading to ingestion incident |
| LVN 3 | Licensed Vocational Nurse | Responded to ingestion incident, monitored Resident 1, and notified LVN 4 |
| LVN 4 | Licensed Vocational Nurse | Completed Change of Condition and notified Resident 1's physician about the ingestion incident |
| RN 1 | Registered Nurse | Observed unlocked Treatment Cart 1 and identified missing key |
| LVN 2 | Licensed Vocational Nurse | Assigned Treatment Cart 1, left it unlocked due to lost key, and did not notify anyone |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 2, 2023
Visit Reason
The inspection was conducted due to an allegation of staff to resident physical abuse involving Resident 1, specifically an alleged assault by a male CNA.
Complaint Details
The complaint involved Resident 1 alleging assault by a male CNA. The facility's investigation was incomplete as it did not include interviews with the male CNAs assigned during the alleged incident or with other residents. The SSD acknowledged these investigative omissions.
Findings
The facility failed to thoroughly investigate the allegation by not interviewing the male CNAs assigned to Resident 1 during the alleged incident and not interviewing other residents to determine if additional abuse occurred. These failures potentially inhibited the facility's ability to determine if abuse occurred and posed a risk for further abuse.
Deficiencies (2)
Failure to conduct interviews with male CNAs assigned to Resident 1 during the time of the alleged assault.
Failure to interview other residents to determine if other residents were potentially assaulted by a male CNA.
Report Facts
Date of alleged incident: Dec 9, 2022
Date of investigation initiation: Dec 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Assigned to care for Resident 1 during evening shift on 12/9/22; not interviewed during investigation |
| CNA 2 | Certified Nursing Assistant | Assigned to care for Resident 1 during night shift on 12/9/22; not interviewed during investigation |
| SSD | Staff Supervisor/Investigator | Conducted investigation; acknowledged failure to interview CNAs and other residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 1, 2023
Visit Reason
The inspection was conducted due to a complaint regarding physical abuse between two residents at the facility.
Complaint Details
The complaint investigation found that Resident 2 physically abused Resident 1 by hitting her with a shoe multiple times on the head, shoulder, and buttock. The abuse was witnessed by staff and confirmed through interviews with Resident 1, Housekeeper 1, and CNA 1. Resident 1 reported feeling awful and wanting to be away from Resident 2.
Findings
The facility failed to protect Resident 1 from physical abuse by Resident 2, who was observed hitting Resident 1 multiple times with a shoe. Interviews and medical record reviews confirmed the incident and the facility's failure to prevent such abuse.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by another resident.
Report Facts
Number of times Resident 2 hit Resident 1: 9
Date of incident: Dec 10, 2022
Inspection Report
Routine
Census: 139
Capacity: 179
Deficiencies: 17
Date: Oct 22, 2021
Visit Reason
Routine inspection of French Park Care Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including timely response to call lights, advance directive documentation, care plan implementation, fall prevention, activity provision, range of motion care, accident hazard prevention, respiratory care, pain management, bed rail consent, medication administration and documentation, infection control, equipment maintenance, and hospice coordination.
Deficiencies (17)
Failed to ensure timely response to call lights resulting in residents remaining in soiled clothing and potential urinary tract infection.
Failed to determine and document residents' advance directives and maintain copies in medical records.
Failed to implement comprehensive care plans including restorative nursing programs and fall risk interventions.
Failed to provide individualized activity programs meeting residents' interests and needs.
Failed to obtain and provide hand and finger splints for contracture management and to perform prescribed range of motion exercises.
Failed to implement fall prevention measures and conduct post-fall neurological assessments as per policy.
Failed to set mechanical ventilator low pressure alarm within safe parameters risking delayed care.
Failed to provide appropriate pain management including documentation of pain assessments and medication effectiveness.
Failed to assess, educate, and obtain informed consent for use of bed rails, placing resident at risk for entrapment.
Failed to follow controlled medication administration, documentation, and destruction policies, risking medication errors and diversion.
Medication error rate exceeded 5% with errors in timing, dosage, and administration technique.
Medication label did not match medication dosage inside packaging, resulting in incorrect dose administration.
Failed to maintain kitchen sanitation including uncovered thawing chicken, dirt buildup, and missing grout on floor tiles.
Failed to accurately document ventilator settings and obtain consent for use of bed rails in medical records.
Failed to coordinate hospice services including obtaining current hospice plan of care, physician certification, and informed consent.
Failed to follow infection control practices by maintenance staff entering isolation room without proper precautions.
Failed to maintain essential equipment safely including leaking oven and illegible glucometer serial number with mismatched test strip lot numbers.
Report Facts
Residents receiving meals prepared in kitchen: 139
Medication error rate: 18.52
Controlled medication count sheets unsigned: 18
Residents affected by deficiencies: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 6 | Licensed Vocational Nurse | Interviewed about call light response times |
| Resident 569 | Resident | Witnessed call light delays and care issues |
| DOR | Director of Rehabilitation | Interviewed about restorative nursing program and splints |
| RN 2 | Registered Nurse | Observed fall prevention measures |
| Activities Director | Activities Director | Interviewed about activity provision and documentation |
| Activities Assistant 1 | Activities Assistant | Interviewed about activity attendance records |
| SSD | Social Services Director | Interviewed about advance directives |
| RT 1 | Respiratory Therapist | Interviewed about ventilator alarm settings |
| RT 2 | Respiratory Therapist | Interviewed about ventilator alarm settings |
| LVN 10 | Licensed Vocational Nurse | Observed pain management and medication administration |
| LVN 11 | Licensed Vocational Nurse | Observed pain management and medication administration |
| LVN 12 | Licensed Vocational Nurse | Interviewed about pain assessment documentation |
| LVN 4 | Licensed Vocational Nurse | Interviewed about bed rail consent documentation |
| LVN 5 | Licensed Vocational Nurse | Observed medication administration and controlled medication count |
| DON | Director of Nursing | Interviewed about medication administration and controlled medication destruction |
| LVN 2 | Licensed Vocational Nurse | Observed medication administration and controlled medication count |
| Maintenance Supervisor | Maintenance Supervisor | Observed entering isolation room without PPE and about oven leak |
| LVN 8 | Licensed Vocational Nurse | Observed medication administration and infection control |
| LVN 3 | Licensed Vocational Nurse | Observed glucometer quality control testing |
| LVN 1 | Licensed Vocational Nurse | Observed medication administration and patch application |
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