Park View Nursing: Resident Needs Accommodation - CA
The resident, identified in inspection records only as Resident 1, has lived with the consequences of catastrophic illness for years. He was first admitted to Park View in January 2017 and readmitted in March 2025 with a diagnosis list that reflects the full weight of his condition: traumatic brain injury, seizures, hydrocephalus, type 2 diabetes, and difficulty swallowing. A physician who evaluated him in March 2025 documented that he does not have the capacity to understand or make decisions for himself. He cannot reposition a brace that is hurting him. He cannot call out to say something is wrong.
His physician ordered ankle-foot orthoses, known as AFOs, placed on both lower legs five times a week, four to six hours at a time, with skin checks while the devices were in place. The braces exist for a specific reason: to prevent foot drop, a condition in which the muscles that lift the foot weaken or stop working, typically from nerve damage or muscle deterioration. Without the brace doing its job, the condition worsens. The joint shortens. The tissue hardens. The deformity becomes permanent.
On the morning of January 30, 2026, a state inspector walked into Resident 1's room at 10:00 a.m. and found him lying on his back in bed. The AFO brace on his right foot and ankle was rotated to the side. It was not cradling the heel, not holding the ankle in alignment, not doing anything the physician had ordered it to do.
Four minutes later, the Director of Rehabilitation stood at Resident 1's bedside alongside the inspector and confirmed what was visible to anyone looking: the brace was not applied correctly. It was rotated to the side of the right foot. The Director of Rehabilitation said the brace should be supporting the foot and ankle to prevent further foot drop.
That afternoon, the restorative nursing assistant who had placed the brace that morning was interviewed. He confirmed he had put the AFO on Resident 1's right leg earlier in the day. He said he did not know it had been applied incorrectly. He acknowledged, when asked, that the brace needed to stay in the correct position to prevent the foot drop from getting worse.
The Director of Nursing, interviewed separately at 3:20 p.m., said staff should be monitoring both the brace placement and the resident's skin condition throughout the hours the device is worn. She said the brace should remain in the correct position at all times.
The facility's own written policy, revised as recently as November 2025, states that staff are trained and demonstrate competency on the use of assistive devices before helping residents with them. A second policy, reviewed in April 2025, commits the facility to providing necessary equipment and assistance to maintain or improve mobility.
The inspection was conducted as a complaint investigation. Regulators rated the violation at the level of minimal harm or potential for actual harm, and noted that few residents were affected. The citation fell under the federal standard requiring facilities to prevent decline in range of motion and mobility unless a medical reason makes decline unavoidable.
There was no medical reason here. There was a brace, and it was on sideways, and a man who cannot speak for himself lay in bed while it sat there doing nothing.
Resident 1 has been in this facility, in one form or another, since 2017. He came back in March 2025. His physician ordered the braces in June. By January, the person applying them did not know when they were wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Nursing and Subacute from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
PARK VIEW NURSING AND SUBACUTE in RESEDA, CA was cited for violations during a health inspection on January 30, 2026.
The resident, identified in inspection records only as Resident 1, has lived with the consequences of catastrophic illness for years.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.