Inspection Reports for North Park Health and Rehabilitation Center
TX, 75071
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to investigate complaints related to PASARR screening accuracy, elopement risk and prevention, and the safety and maintenance of the facility environment.
Complaint Details
The complaint investigation included review of PASARR screening inaccuracies for Resident #19, elopement incident involving Resident #20, and environmental maintenance issues affecting multiple resident rooms and bathrooms. The PASARR screening was found inaccurate and a correction was submitted. Resident #20 eloped due to unsecured front door after hours and lack of wander guard. Environmental deficiencies included damaged walls, rotted wood, peeling linoleum, and unaddressed maintenance issues.
Findings
The facility failed to complete accurate PASARR evaluations for residents, failed to prevent elopement of a high-risk resident due to inadequate supervision and door security, and did not maintain a safe, clean, and comfortable environment due to maintenance and repair deficiencies in multiple resident rooms and bathrooms.
Deficiencies (3)
Failed to complete an accurate PASARR evaluation on residents prior to admission and after admission for 1 of 7 residents reviewed for PASARR screenings.
Failed to ensure residents were free of accident hazards and received adequate supervision to prevent elopement for 1 of 6 residents reviewed for accidents and hazards.
Failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 6 halls reviewed for environment due to walls, floors, and bathrooms in poor repair.
Report Facts
Residents reviewed for PASARR screenings: 7
Residents reviewed for accidents and hazards: 6
Elopement assessment scores: 7
Elopement assessment scores: 21
Elopement assessment scores: 24
BIMS score: 7
Date of PASARR Level 1 Screening: PASARR Level 1 Screening dated 1/12/24 for Resident #19.
Date of History and Physical: History and Physical dated 3/1/24 for Resident #19.
Date of elopement: Resident #20 eloped on 04/21/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Reported Resident #19 refused care and showers; also interviewed regarding environmental maintenance issues. |
| MDS Nurse A | MDS Nurse | Submitted PASARR forms and correction for Resident #19. |
| Administrator | Facility Administrator | Acknowledged inaccurate PASARR screening and environmental concerns; provided policy and interview statements. |
| LVN D | Licensed Vocational Nurse | Provided information about secure unit doors and wander guard system. |
| Aide A | Nursing Aide | Discussed supervision to prevent elopement on secure unit. |
| LVN C | Licensed Vocational Nurse | 500 Hall Charge Nurse; provided information on resident wandering and maintenance reporting. |
| Aide B | Nursing Aide | Reported seeing Resident #20 outside facility and door alarm not sounding. |
| Aide C | Nursing Aide | Familiar with Resident #20's wandering behavior. |
| DON | Director of Nursing | Discussed investigation of Q15 checklist and expectations for maintenance reporting. |
| Maintenance Specialist | Maintenance Specialist | Tested wander guard doors and described maintenance procedures. |
| LVN E | Licensed Vocational Nurse | Provided information on abuse neglect training and elopement prevention. |
| Maintenance Director | Maintenance Director | Discussed maintenance priorities, work orders, and environmental issues. |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, PASARR screenings, accident hazards prevention, environmental safety, and maintenance in a nursing home facility.
Findings
The facility failed to ensure accurate resident assessments, proper PASARR screenings, adequate supervision to prevent elopement, and maintenance of a safe, clean, and comfortable environment. Specific deficiencies included inaccurate MDS assessments, failure to identify mental illness in PASARR screenings, unsecured front door leading to resident elopement, and multiple maintenance issues such as damaged walls, floors, and bathrooms.
Deficiencies (4)
Failed to ensure Resident #4's MDS Assessment accurately reflected urinary status.
Failed to complete accurate PASARR evaluation for Resident #19, missing mental illness diagnoses.
Failed to ensure adequate supervision and secure front door to prevent elopement of Resident #20.
Failed to provide a safe, functional, sanitary, and comfortable environment; walls, floors, and bathrooms in poor repair in multiple rooms.
Report Facts
Residents reviewed for assessment accuracy: 18
Residents reviewed for PASARR screenings: 7
Residents reviewed for accidents and hazards: 6
Elopement assessment scores: 7
Elopement assessment scores: 21
Elopement assessment scores: 24
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Licensed Vocational Nurse | Provided regular care for Resident #4 and stated Resident #4 never utilized a urinary catheter. |
| MDS Nurse G | MDS Nurse | Acknowledged documentation error on Resident #4's MDS Assessment and submitted correction. |
| LVN B | Licensed Vocational Nurse | Reported Resident #19 refused care and showers at times. |
| MDS Nurse A | MDS Nurse | Submitted PASARR forms and acknowledged failure to verify Resident #19's mental illness indicators. |
| Administrator | Facility Administrator | Acknowledged inaccurate PASARR screen and maintenance issues; discussed elopement risks and facility policies. |
| LVN D | Licensed Vocational Nurse | Worked on secure unit and described door security and resident supervision practices. |
| Aide A | Nursing Aide | Worked on secure unit and described supervision to prevent elopement. |
| LVN C | Licensed Vocational Nurse | 500 Hall Charge Nurse, aware of maintenance issues and resident wandering behaviors. |
| Aide B | Nursing Aide | Reported seeing Resident #20 outside the facility and door alarm not sounding. |
| Maintenance Specialist | Maintenance Specialist | Tested wander guard alarms and described monthly maintenance procedures. |
| Maintenance Director | Maintenance Director | New to facility, aware of maintenance issues, described repair challenges and risks to residents. |
| DON | Director of Nursing | Expected nursing staff to report maintenance issues and described risks of environmental deficiencies. |
| LVN B | 600 Hall Charge Nurse | Reported use of app for maintenance issues and lack of awareness of cosmetic issues in bathrooms. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
The inspection was conducted as an annual survey of North Park Health and Rehabilitation Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as an annual survey of North Park Health and Rehabilitation Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to obtain informed consent for psychoactive medication administration to Resident #1.
Complaint Details
The complaint investigation found that the facility did not obtain documented consent for Resident #1's Sertraline HCl medication despite administration from 05/27/23 through 07/20/23. Interviews with the LVN, Director of Nursing, and Resident's Responsible Party confirmed the oversight and lack of documented consent. The facility policy requires documented written consent prior to administration of psychotropic medications.
Findings
The facility failed to obtain a signed consent prior to Resident #1 receiving Sertraline HCl, a psychoactive medication, potentially affecting all residents receiving antidepressant medications by voiding their opportunity to make informed choices about their care. Interviews and record reviews confirmed the lack of documented consent despite the medication being administered from admission.
Deficiencies (1)
Failure to inform resident in advance of the risks and benefits of proposed care, treatment alternatives, and to obtain signed consent for psychoactive medication Sertraline HCl prior to administration.
Report Facts
Residents reviewed for resident rights: 5
Medication administration dates: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitting nurse responsible for obtaining consent for Resident #1's Sertraline HCl medication but failed to do so |
| DON | Director of Nursing | Oversaw consent process, acknowledged oversight in entering consent for Sertraline HCl, and confirmed facility policy on psychotropic medication consent |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 7, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living assistance and environmental safety in the nursing home.
Findings
The facility failed to provide adequate fingernail care for a resident dependent on staff for ADLs, and failed to maintain a safe, sanitary environment by leaving dirty breakfast trays on treatment carts and uncovered food items on medication carts, posing infection control risks.
Deficiencies (2)
Failure to provide necessary services for residents unable to perform activities of daily living, specifically inadequate fingernail care for Resident #1.
Failure to maintain a safe, functional, sanitary, and comfortable environment by leaving a dirty breakfast tray on a treatment cart and uncovered thickened orange juice, applesauce, and pudding on a medication cart.
Report Facts
Residents reviewed for ADLs: 4
Residents affected: 1
Residents affected: 1
Residents per CNA: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Interviewed regarding fingernail care schedule and Resident #1's preferences | |
| LVN N | Interviewed acknowledging Resident #1's fingernails were sharp and dirty and stating she would clean and trim them | |
| ADON | Interviewed regarding nail care policies and infection control risks related to long and dirty nails | |
| CNA A | Interviewed about removal of dirty breakfast trays and infection control practices on the 400 hall | |
| LVN B | Interviewed about staff responsibilities for removing dirty breakfast trays and infection control issues with uncovered food on medication cart |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 6
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accident prevention, catheter care, medication storage, food safety, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not providing privacy covers for catheter bags, inadequate supervision and improper transfer techniques for residents, improper catheter care risking urinary tract infections, unsecured medication storage, improper food storage, and failure to perform proper hand hygiene during incontinent care.
Deficiencies (6)
Failed to treat resident with respect and dignity by not providing privacy covers for catheter bags.
Failed to ensure adequate supervision and use of assistive devices during resident transfers.
Failed to provide appropriate catheter care to prevent urinary tract infections by not keeping catheter bag below bladder level.
Failed to ensure all drugs were stored in locked compartments and medications were not left unsecured in resident rooms.
Failed to properly store food in the kitchen; food items were open and exposed to air.
Failed to perform hand hygiene during incontinent care, risking infection transmission.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Interviewed regarding lack of privacy covers and catheter bag positioning |
| LVN A | Licensed Vocational Nurse | Interviewed regarding improper transfer techniques |
| Restorative Aide | Interviewed regarding transfer procedures and gait belt use | |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding improper transfer and hand hygiene |
| ADON C | Assistant Director of Nursing | Interviewed regarding transfer supervision and gait belt use |
| DON | Director of Nursing | Interviewed regarding transfer procedures, catheter care, medication administration, and infection control |
| LVN F | Licensed Vocational Nurse | Interviewed regarding medication administration and leaving medications unsecured |
| Dietary Manager | Interviewed regarding food storage practices | |
| Administrator | Interviewed regarding facility policies on privacy covers, medication storage, and other procedures |
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