Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Park Post-acute during CMS and state inspections, most recent first.
A resident with severe dementia, documented wandering risk, and an active wander guard order eloped during the night through an unalarmed and unlocked laundry exit door located outside the main patient care area. The resident’s care plan identified elopement risk and called for frequent checks, redirection, and use of a wander guard, but on the night of the incident the resident was left in an activities room under CNA supervision while the assigned nurse assisted an x-ray technician and then went on break. No door alarms sounded, and staff discovered the resident missing only after the roommate inquired about her whereabouts. Police later located the resident in a nearby private home, and EMS transported the resident to a hospital, where an acute NSTEMI and acute altered mental status were diagnosed.
A resident was issued a 30-Day Notice of Discharge/Eviction for denial of payment while a Medi-Cal application was still pending, despite facility staff being aware of the pending status and regulations prohibiting discharge under these circumstances. Staff interviews and documentation confirmed the facility's knowledge of the application, and the resident's right to remain was not upheld.
A resident with diabetes experienced severe hypoglycemia and seizures due to the facility's failure to monitor blood glucose levels and manage her diabetic condition properly. The resident's insulin regimen was changed without ensuring BG monitoring orders were in place, leading to a critically low blood sugar level and hospitalization.
The facility failed to maintain food safety and sanitation standards, with issues such as a dietary aide not wearing a hairnet, wet nesting of glasses and containers, expired yogurt available for consumption, and improper dishwasher sanitization. Additionally, dust and debris were found in utensil drawers and on kitchen surfaces, and dented cans were stored improperly, posing risks to resident safety.
A resident in an LTC facility received a lower dose of Lorazepam than prescribed, resulting in significant medication errors. The resident was supposed to receive 1 mg every six hours, but instead received 0.5 mg on multiple occasions, which was incorrectly documented as the full dose. The DON confirmed the error, and the facility's medication administration policies were not followed.
The facility failed to document COVID-19 vaccination education for several residents, as confirmed by the Infection Preventionist and the DON. The facility's policy requires education on vaccine benefits, risks, and side effects before offering it, but this was not documented in the residents' medical records.
The facility failed to ensure safe insulin use for two residents with diabetes. One resident's insulin order lacked parameters for high blood sugar, and frequent high readings were not addressed or reported to the MD. Another resident's insulin use was not monitored by blood sugar measurements. Facility policies on diabetes management were not followed, and staff interviews revealed a lack of awareness and action regarding these issues.
The facility failed to maintain a homelike environment for two residents. One resident had a black rubber strip in her room, posing a tripping hazard, while another had broken blinds. The strip was installed due to broken tiles and had been in place for over a year, with staff acknowledging it as a hazard. The blinds were missing a section, and the resident expressed a desire for replacement. Facility policies emphasize maintaining a dignified and orderly environment, which was not upheld.
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, a medication cart contained an outdated Lantus insulin pen, and at the North station, a treatment cart stored an opened bottle of Sterile Sodium Chloride intended for single use. These lapses were acknowledged by the nursing staff and the Director of Nursing.
The facility failed to document education for immunizations for two residents. One resident's Influenza vaccination record lacked documentation of education, and another resident's records for both Influenza and Pneumococcal vaccines were missing education documentation. The facility's policies require that education about the benefits and potential side effects of vaccines be provided and documented in the resident's medical record.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to inadequate care. One resident with skin integrity issues did not have a care plan initiated until eight days post-admission. Another diabetic resident lacked a care plan, resulting in a fall due to low blood sugar, hospitalization, and seizures. The DON confirmed the absence of necessary care plans, which are crucial for effective treatment and monitoring.
A resident with diabetes was admitted to a facility without proper orders for blood glucose monitoring or emergency diabetic medication. The attending physician did not provide necessary instructions, and the nursing staff failed to implement hospital orders. This oversight resulted in the resident experiencing severe hypoglycemia, leading to a fall, hospitalization, and new onset seizures.
The facility failed to follow its medication administration policy for three residents. An LPN did not sign off medications at the time of administration, another LPN administered morning medications late, and a third LPN left the medication cart unattended with medications on top. These actions were confirmed through record reviews and staff interviews.
Elopement of Cognitively Impaired Resident Through Unalarmed Laundry Exit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent an elopement for a resident with severe cognitive impairment and known wandering risk. The resident was admitted with encephalopathy, delirium, gait and mobility abnormalities, need for assistance with personal care, and dementia. A Brief Interview for Mental Status (BIMS) score of 1 indicated severe impairment in thinking and memory. The resident’s care plan, initiated months earlier, identified risk for wandering or elopement related to exit-seeking behavior, a focus on wanting to go home, dementia, and aimless wandering, with goals to prevent elopement and maintain safety. Interventions included frequent checks of the resident’s whereabouts, redirection when approaching exit doors, assessment for a wander/elopement alarm, and application of a wander guard as ordered. An active order for wander guard placement due to exit-seeking behavior was in place. On the night of the incident, documentation showed that the resident was last seen by the night shift CNA walking up and down the hallway at approximately 2:35 a.m., and the resident’s roommate later came out to inquire about the resident when she was no longer in the room. Staff then determined the resident was not in the building and began searching the premises. The assigned nurse (LN 3) reported being responsible for 30 residents that shift and stated that around 1:50 a.m. she accompanied an x-ray technician to assist with other residents, leaving the resident under the supervision of the CNA in the activities room because the resident did not want to remain in bed. LN 3 remained with the x-ray technician until about 2:30 a.m. and then took her scheduled lunch break, assuming the resident remained under CNA supervision. LN 3 later became aware the resident was missing when the roommate asked about her whereabouts and initially believed the resident was still in the building because no door alarm had sounded. Interviews and record review revealed that the resident eloped through a laundry room exit door that was not alarmed and that a second laundry door, which was supposed to be locked from the inside when staff left the area, had been left unlocked. The Administrator stated that prior to the elopement, all exit doors except the laundry door were alarmed, and that staff had forgotten to lock the second laundry door on the night of the incident. The Interdisciplinary Team note documented that the resident, who was alert and ambulatory at the time of exiting, left through a door that did not have an alarm and was outside the patient care area, and that the wander guard did not alarm for this door. Police records indicated that officers responded to a missing person call, searched the surrounding area, and later received a call from a community member reporting an unknown female in her home wearing a yellow gown; officers identified this person as the resident. Due to extreme cold weather, the resident’s age, and health conditions, EMS transported the resident to a hospital, where she was diagnosed with an acute NSTEMI and acute altered mental status, with elevated troponin and treatment including heparin and cardiac monitoring. Facility policies on wandering, elopement prevention and management, and safety and supervision of residents required identification of residents at risk for unsafe wandering or elopement, inclusion of detailed monitoring plans in the care plan, provision of adequate supervision, and maintenance and utilization of electronic monitoring and door alarm systems when deemed appropriate. Policies also described that a missing resident is considered a facility-wide emergency and outlined notification procedures for the Administrator, DON, legal representative, physician, and law enforcement if a resident is not located. Despite these policies and the resident’s documented risk factors and care plan interventions, the resident was able to leave the building through an unalarmed and unlocked laundry exit without staff knowledge, remained missing for several hours during nighttime and early morning hours, and was ultimately found offsite and transported to the hospital, where an acute cardiac injury (NSTEMI) was diagnosed.
Improper Discharge Notice Issued During Pending Medi-Cal Application
Penalty
Summary
The facility failed to comply with transfer and discharge requirements when it issued a 30-Day Notice of Discharge/Eviction to a resident and the resident's responsible party due to a denial of payment, despite the resident having a pending Medi-Cal application. Documentation in the social services notes confirmed that the facility was aware the Medi-Cal application was under review at the time the notice was issued. The responsible party also acknowledged that the application was still pending and not yet active. Interviews with facility staff, including the Social Service Director and Social Services Assistant, confirmed that the resident had a right to remain in the facility while the Medi-Cal application was pending or under appeal. The Administrator later confirmed that Medi-Cal coverage was approved retroactively. Reference to state advocacy guidance indicated that facilities are prohibited from discharging residents with timely Medi-Cal applications pending eligibility determination, and that an appeal suspends a finding of nonpayment. The issuance of the discharge notice under these circumstances constituted a failure to meet regulatory requirements.
Failure to Monitor Diabetic Resident Leads to Severe Hypoglycemia and Seizures
Penalty
Summary
The facility failed to provide quality care to Resident 596, a diabetic patient, who experienced a series of critical events due to inadequate monitoring and management of her condition. Resident 596 was admitted with a diagnosis of diabetes and was on insulin and oral anti-diabetic medications. However, the admitting nurse did not include blood glucose (BG) testing parameters in the resident's orders, and the attending physician did not ensure BG monitoring orders were in place after changing the resident's insulin regimen. This oversight led to a lack of BG monitoring, which is crucial for managing diabetes effectively. On 9/20/24, Resident 596 suffered an unwitnessed fall due to critically low blood sugar levels, resulting in injuries and seizures. The licensed nurse on duty failed to implement emergent nursing interventions to assess the resident's BG level after the fall and did not inform Emergency Medical Services (EMS) of the resident's diabetic status or her last insulin dose. Consequently, Resident 596 was found with a blood glucose level of 20, significantly below the normal range, and was admitted to the intensive care unit (ICU) for treatment of severe hypoglycemia and seizures. The attending physician acknowledged the system failure, admitting that she did not write orders for BG monitoring or a sliding scale for insulin administration. The physician also recognized the risk of death, seizures, or hypoglycemic events due to the lack of proper diabetic management. The facility's policies and procedures for managing diabetes and medication administration were not followed, contributing to the resident's critical condition and subsequent hospitalization.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service and safety, as evidenced by multiple deficiencies observed in the kitchen area. A dietary aide was seen not wearing a hairnet, which is essential to prevent hair from contaminating food. Additionally, drinking glasses and food containers were found wet nested, a practice that can promote bacterial growth. Clean fruit cups were stored under a dishwasher with water dripping onto them, and expired yogurt was available for resident consumption, all of which pose significant risks to food safety. The dishwasher was not functioning within the required parameters, with its water temperature below the necessary 120 degrees Fahrenheit and the parts per million of the dishwashing solution below the accepted standard. This failure in maintaining proper sanitization levels could compromise the cleanliness of dishes used by residents. Furthermore, two utensil drawers contained dust and debris, and two dented cans of corn were found in the food storage area, both of which are against the facility's sanitation policies. The kitchen environment itself was not maintained in a sanitary condition, with three fans in the food preparation area and the counter above the stove top covered in dust and debris. These conditions could lead to contamination of food prepared for the 89 residents receiving meals from the facility. The facility's policies on sanitization and food storage were not followed, as evidenced by these observations, which could potentially lead to foodborne illnesses among residents.
Medication Administration Error for Anti-Anxiety Medication
Penalty
Summary
The facility failed to administer an anti-anxiety medication, Lorazepam, correctly to a resident, resulting in significant medication errors. The resident was prescribed Lorazepam 1 mg to be taken every six hours for agitation with behaviors, starting from late April 2024. However, during May and September 2024, the resident received a lower dose of 0.5 mg on multiple occasions, which was incorrectly documented as 1 mg in the Medication Administration Record (MAR). Specifically, the resident received the incorrect dose 18 times in May and once in September, as evidenced by discrepancies between the Controlled Drug Record (CDR) and the MAR. The Director of Nursing confirmed that the resident did not receive the medication as ordered by the physician, acknowledging the administration of only half the prescribed dose. The facility's policies on controlled medication administration and specific medication administration procedures were not followed, as the documentation did not accurately reflect the amount administered. This failure in adhering to the facility's guidelines and physician's orders had the potential to cause increased anxiety and emotional distress for the resident.
Failure to Document COVID-19 Vaccination Education
Penalty
Summary
The facility failed to provide documented evidence of education regarding COVID-19 vaccinations for four sampled residents and one unsampled resident. During a review of the clinical records, it was found that the records for these residents did not contain documentation indicating that education on the benefits, risks, and potential side effects of the COVID-19 vaccine was provided. This lack of documentation was confirmed during an interview with the Infection Preventionist, who acknowledged that the section titled 'Education Provided to Resident/Family' was not checked in the medical records of the affected residents. The Director of Nursing explained that providing education to residents before administering or refusing a vaccination is crucial as it gives them sufficient information about the medication, including its risks and benefits, allowing them to make an informed decision. The facility's policy on COVID-19 vaccination, revised in October 2023, mandates that residents and staff be educated about the vaccine before it is offered, and that the resident's medical record should include documentation of this education. However, this policy was not adhered to in the cases of the identified residents.
Failure to Ensure Safe Insulin Use for Diabetic Residents
Penalty
Summary
The facility failed to ensure the safe use of insulin for two residents with diabetes, leading to potential unsafe insulin and antidiabetic drug use. Resident 1's insulin order lacked parameters for addressing high blood sugar levels, and there was no documentation of additional treatments or interventions despite frequent high blood sugar readings. The medical doctor was not notified of these high readings, and the resident's care plan, which required notification of the doctor for blood sugar levels above 400, was not followed. Interviews with staff and the medical doctor revealed a lack of awareness and action regarding the resident's high blood sugar levels. Resident 596's diabetic medication and insulin use were not monitored by blood sugar measurements, indicating a failure in monitoring and managing the resident's diabetes. The facility's policies on managing diabetes and medication administration were not adhered to, as evidenced by the lack of intervention for high blood sugar levels and the absence of a sliding scale for insulin administration. The Director of Nursing acknowledged that the nursing staff should have contacted the doctor to obtain parameters for managing blood sugar variations.
Failure to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, Resident 382 and Resident 3, as observed during a survey. For Resident 382, the floor tiles in her room were replaced with a black rubber strip, which was not uniform with the rest of the rooms and posed a tripping hazard. The Responsible Party for Resident 382 expressed concerns about the strip, having tripped over it in the past. The Maintenance Director confirmed the strip was installed due to broken tiles and had been in place for over a year. The Certified Nurse Assistant also noted the strip as a potential hazard, especially for wheelchairs. The Administrator and Director of Nursing were unaware of the strip's presence and acknowledged it was not in line with the facility's homelike environment policy. For Resident 3, the deficiency involved broken blinds in her room, which had been missing a section for some time. Resident 3 expressed a desire for the blinds to be replaced, describing them as looking "shaggy." The Director of Staff Development and the Director of Nursing both confirmed that blinds should be well-fitting and not broken to maintain a homelike environment. The facility's policies on resident rights and maintenance emphasize the importance of maintaining a dignified and orderly environment, which was not upheld in these instances.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during a survey. At the South station, Medication Cart #4 contained an outdated Lantus insulin pen, which had been opened and was beyond its use date of 28 days after opening. This was acknowledged by Licensed Nurse 5 during an inspection. Additionally, at the North station, the treatment cart stored an opened bottle of Sterile Sodium Chloride, which is intended for single use and should have been discarded after use. Licensed Nurse 6 confirmed that the bottle should have been disposed of. The Director of Nursing acknowledged these findings, stating that the insulin pen should have been discarded after 28 days and that single-use products should be discarded after use. The facility's policy on medication storage requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedure. These lapses in medication storage practices could result in residents receiving expired or unusable medications.
Failure to Document Vaccine Education for Residents
Penalty
Summary
The facility failed to provide documented evidence of education for immunizations to two residents, Resident 14 and Resident 23. For Resident 14, the Influenza vaccination record dated 9/29/23 did not have the education box checked, and the Infection Preventionist (IP) confirmed there was no documentation of education provided regarding the vaccine. Similarly, for Resident 23, the Influenza vaccination record dated 12/13/23 also lacked documentation of education, and the IP acknowledged this omission. The facility's policy requires that education about the benefits and potential side effects of the influenza vaccine be provided and documented in the resident's medical record. Additionally, Resident 23's record for the Pneumococcal Polysaccharide (PPSV 23) vaccine, dated 5/6/21, also did not have the education box checked, and the IP confirmed the absence of documented education. The Director of Nursing (DON) emphasized the importance of providing education to residents before administering or refusing a vaccination to ensure they have sufficient information about the risks and benefits. The facility's policy mandates that education about the pneumococcal vaccine be provided and documented, and any refusal of the vaccine should be recorded in the resident's medical record.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents, leading to significant deficiencies in care. Resident 545 was admitted with multiple diagnoses, including enterocolitis due to C. Diff, dementia, and generalized muscle weakness. Despite the presence of redness in the right groin, left groin, and perirectal area upon admission, the baseline care plan addressing these skin integrity issues was not initiated until eight days later. This delay in care planning was confirmed by the Director of Nursing (DON) during a review of the resident's medical records. Resident 596, who was admitted with a diagnosis of diabetes, did not have a diabetic baseline care plan developed to manage her condition and medications, including insulin and oral antidiabetic drugs. The admitting nurse failed to enter the necessary orders for hypoglycemia and hyperglycemia protocols. As a result, Resident 596 experienced a fall due to low blood sugar, leading to hospitalization and subsequent adverse events, including seizures. The DON confirmed that a diabetic care plan was not in place, which was crucial for directing the care of the resident. The facility's policy requires a baseline care plan to be developed within 48 hours of admission to meet the resident's immediate needs. However, the lack of timely care plans for both residents resulted in inadequate monitoring and management of their conditions. The DON acknowledged the importance of care plans in creating a pathway of care and ensuring effective treatment, which was not achieved in these cases.
Failure in Diabetic Care Management Leads to Resident Hospitalization
Penalty
Summary
The attending physician (AP) failed to provide necessary orders for routine blood glucose monitoring and adequate oversight for a diabetic resident, identified as Resident 596. Upon admission, the resident had a diagnosis of diabetes and was receiving multiple medications for its management. However, the admitting orders from the hospital, which included instructions for blood glucose monitoring and parameters for notifying the physician in case of significant changes, were not implemented by the facility. The AP did not include these orders in the resident's Order Summary Report, nor did they provide orders for emergency diabetic medication administration or parameters for managing hypoglycemia or hyperglycemia. The nursing staff, under the direction of Licensed Nurse (LN) 3, failed to ensure the admitting orders were accurately entered into the system. Although LN 3 stopped the NPH insulin as per the AP's verbal instructions, there were no written orders to guide the nursing staff on blood glucose monitoring or emergency interventions. The AP's notes, which were faxed to the facility days later, did not include necessary orders for managing the resident's diabetes effectively. Consequently, the resident's blood glucose levels were not monitored adequately, and no emergency protocols were in place to address potential hypoglycemic or hyperglycemic events. As a result of these oversights, Resident 596 experienced a severe hypoglycemic event, leading to a fall and subsequent hospitalization. The resident was found with a critically low blood glucose level and suffered new onset seizures, which were attributed to the severe hypoglycemia. The facility's Medical Director and Director of Nurses acknowledged the lack of appropriate orders and monitoring, highlighting the risk posed to the resident due to the absence of a structured diabetes management plan.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to follow its policy and standards of practice for medication administration for three residents. Licensed Nurse (LN) 2 did not sign off medications at the time of administration for Residents 1, 2, and 3. Medications for these residents were signed off hours after they were due, which was confirmed through a review of the Medication Administration Audit Report (MAAR) and interviews with LN 2 and other staff members. LN 2 admitted to administering medications on time but signing them off later when she had time, which contradicts the facility's policy and places residents at risk for medication errors. Additionally, LN 6 administered morning medications late to Resident 1. The MAAR indicated that medications scheduled for 7 AM were administered between 8:56 AM and 9:04 AM. LN 6 confirmed during an interview that the medications were passed late. The Director of Nurses (DON) emphasized the importance of timely medication administration to ensure the therapeutic effect of the medications. Furthermore, LN 4 left the medication cart unattended with medications on top during a medication pass. This occurred when LN 4 was interrupted by a resident's family member. LN 4 acknowledged the mistake and explained the importance of securing medications to prevent unauthorized access. The DON reiterated the importance of securing medications to ensure resident safety. The facility's policy mandates that medications be administered within one hour of their prescribed time and that the medication cart be kept closed and locked when out of sight.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tracy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tracy Nursing And Rehabilitation Center | 0.7 mi | — | 18 | 0 |
| Guardian Care And Rehabilitation Center | 12.3 mi | — | 9 | 0 |
| Harvest Crossing Post Acute | 12.4 mi | — | 3 | 0 |
| Lincoln Square Post Acute Care | 15.9 mi | — | 1 | 0 |
| Good Samaritan Rehab And Care Center | 16.2 mi | — | 1 | 0 |
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