Deer Park Health and Rehabilitation

Inspectors wroteBased on record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31 (normal 80-100), was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. [...]

Inspectors wroteBased on observation, record review, staff, resident, family, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's (Resident #1) right to be free from neglect when the facility failed to ensure Resident #1 received emergent care extending beyond the capabilities of the facility when she had critically low blood sugar and was symptomatic. Symptoms included lack of responsiveness, eyes moving left to right, obtunded, jaw tightness, inability to swallow, tightness of hands, moaning, foaming at the mouth. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. [...]

Inspectors wroteBased on observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31 (a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. [...]

Inspectors wrote2. Resident #15 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included: displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle wasting/atrophy multiple sites, and primary osteoarthritis. Resident #15's care plan was last updated on 11/08/24 as being at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs, wandering and history of falls and used a reclining chair, with interventions that included fall mat at bedside, anticipate resident's needs, and bed in lowest position while resident is in bed. [...]

Inspectors wroteBased on record reviews, resident, observation, staff, Physician Assistant (PA), Transport Company's Owner, and Driver #1 (Transport Company's Driver) interviews, the facility failed to ensure a resident was safely secured in the transport company's van during the return trip from an appointment back to the facility. On 3/26/25 Driver #1 failed to secure Resident #101 in a specialized wheelchair in the Transport Company's van per manufacturer's instructions and according to Driver #1 when the van hit a bump pulling into facility entrance, Resident #101 fell forward, landing partially out of her wheelchair with her legs under the chair. Resident #101 was assisted back into the wheelchair by facility staff at the facility and was wheeled inside the facility. [...]

Inspectors wroteBased on record review, and staff, mobile x-ray company representative, and Physician Assistant and Physician interviews, the facility failed to notify the provider of x-ray results when they were reported to the facility on [DATE], which resulted in Resident #15's right hip fracture not being reported to a provider until 12/30/24 which delayed Resident #15's transfer to the hospital until 12/30/24 for an evaluation and treatment for a right hip fracture that required surgical intervention for 1 of 4 residents reviewed for falls (Resident #15).

Inspectors wroteBased on observation, record review, resident, staff and provider interviews, the facility failed to administer medications as ordered by the physician for 1 of 2 residents reviewed for pain medications (Resident # 106).

Inspectors wroteBased on observations, record review and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 13 of 36 residents reviewed for respiratory care (Resident #78, #90, #45, #32, #4,#10, #27, #61, #3, #36, #26, #57, #67).

Inspectors wroteBased on record review, staff, and Consulting Pharmacist, Psychiatric Nurse Practitioner, and Physician interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #15).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to follow their planned menus for 3 of 3 residents reviewed for preferences (Residents #96, #3, #111). The deficient practice had the potential to affect other residents who received food from the kitchen.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to provide evening snacks to residents when requested for 6 of 6 residents reviewed for frequency of snacks (Residents #3, #37, #44, #96, #105 and #111). This deficient practice had the potential to affect other residents who requested evening snacks.

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired food and failed to date perishable food stored for use in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility staff failed to implement infection control policy and procedures when Nurse #12 did not don personal protective equipment (PPE) for enhanced barrier precautions (EPB) when providing high-contact resident care activities for Resident #106 who had a gastrostomy tube (g-tube-a tube that goes into stomach), an indwelling urinary catheter, and a tracheostomy tube (a tube in the throat for breathing). The facility also failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 3 residents whose blood sugar levels were checked (Resident #96, Resident #10). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. [...]

Inspectors wroteBased on record reviews, and resident, staff, Physician Assistant (PA), and Physician interviews, the facility failed to protect resident's right to be free of misappropriation of controlled substances for 1 of 3 residents reviewed for misappropriation of resident property (Resident #117).

Inspectors wrote2. Resident #126 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 04/10/25. A progress note dated 04/10/25 indicated Resident #126 was discharged home with a friend and his medications were given to him upon discharge. Resident #126's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed he was discharged to short term general hospital. During an interview on 06/20/25 at 3:19 PM with the MDS Coordinator and the Regional MDS Coordinator they stated Resident #126 was discharged home with a friend and his assessment was miscoded as being discharged to short term general hospital. The MDS Coordinator stated she would amend the discharge assessment and correct the assessment to reflect the resident was discharged to the community. [...]

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan in the areas of pain management and opioid (pain medication) use for 1 of 4 residents whose comprehensive care plans were reviewed (Resident #117).

Inspectors wroteBased on observations, record review, and staff, Physician Assistant (PA), and Dialysis Nurse interviews, the facility failed to follow the physician's orders to remove a dressing to an arterial venous fistula (a surgically created connection between artery and vein in the arm used for dialysis treatments) at 9:00 PM after dialysis treatment to monitor for bleeding at the access site and to prevent potential damage to the access site and provide a bagged meal or snack for 1 of 2 residents reviewed for dialysis (Resident #101).

Inspectors wroteBased on record review, medication administration observations, and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the omission of two medications due to being unavailable (2 medication errors out of 30 opportunities), resulting in a facility medication error rate of 6.67% for 1 of 13 residents (Resident #106) observed during medication pass.

Inspectors wroteBased on record reviews and resident, staff, Physician Assistant, and Physician interviews, the facility failed to prevent a significant medication error when nursing staff failed to administer a scheduled pain medication as ordered by the physician. Resident #117 was ordered to receive a scheduled pain medication twice a day and failed to receive a morning dose of scheduled pain medication due to the medication not being available at the facility. This deficient practice occurred for 1 of 2 residents reviewed for significant medication errors (Resident #117).

Inspectors wrote2. Review of the manufacturer's recommendations revealed the Acetylcysteine medication vial was good for 96 hours after opening if refrigerated. An observation of the North Hall medication storage room was conducted on 06/17/2025 at 12:07 PM with the Director of Nursing (DON). An opened multi-use vial of Tuberculin Purified Protein Derivative with a manufacturer's expiration date of 01/2028 was found in the North Hall medication room in the refrigerator. The tuberculin vial was not labeled with an open date. An observation of the South Hall medication storage room was conducted with the Director of Nursing (DON) on 06/17/2025 at 12:37 PM. An opened multi-use vial of Acetylcysteine Solution (inhalation medication used to relieve chest congestion due to thick mucus secretions) with a manufacturer's expiration date of 02/2026 was found in the top right drawer of the medication room. [...]

Inspectors wroteBased on observations, record review and staff, Physician Assistant, and Medical Director interviews, the facility failed to supervise a severely cognitively impaired resident with wandering behaviors from exiting the facility unsupervised, without staff knowledge, for 1 of 1 resident reviewed for accidents related to unsafe wandering/elopement (Resident #1). The facility also failed to immediately notify administration of the missing resident. The resident exited the facility which was in a rural residential area and walked 1/3 mile on a two-lane road with no streetlights and no sidewalk without shoes, wearing socks. She was found lying in a ditch beside the road by a neighbor walking his dog. On evaluation by Emergency Medical Service personnel, Resident #1's blood sugar was 500 milligrams per deciliter. [...]

Inspectors wroteBased on observations and record review the facility failed to remove an accident hazard (grill with 2 propane tanks) from the resident smoking area. In addition, the facility did not have a policy for safe operation of a gas grill in a common area used by residents. The resident smoking area contained 21 of 22 residents who smoked at the facility when the grill and 2 propane tanks were present.

Inspectors wroteBased on observation, record reviews, and resident, resident representatives, staff, psychotherapist, Psychiatric Nurse Practitioner (NP), Physician Assistant and Medical Director interviews, the facility failed to protect a resident's right (Resident #3) to be free of sexual abuse from another resident (Resident #52). Resident #3 had severely impaired cognition and Resident #52 had moderately impaired cognition and a history of sexual behaviors. On 3/25/23 Resident #52 was observed by staff inviting Resident #3 into his room and was told by staff to leave the door open. Shortly after, Resident #52 was observed inappropriately touching Resident #3's leg. On 7/25/23 Resident #52 was found in Resident #3's room looking at her while she slept. On 1/30/24 Nurse Aide (NA) #1 heard yelling coming from Resident #3's room. [...]

Inspectors wroteBased on record review and staff, Transportation Driver, Dialysis Nurse, and Medical Director (MD) interviews, the facility failed to assess a resident after a fall prior to moving them from the floor. Resident #103 fell during a transfer at the dialysis center and was moved off the floor prior to being assessed for injuries. Resident #103 sustained a clavicle fracture and right ankle strain. This was for 1 of 2 sampled residents reviewed for quality of care (Resident #103).

Inspectors wroteBased on observation, record review, and resident, family member, Transportation Driver, Dialysis Center staff, and Medical Director interviews, the facility failed to ensure a resident was transferred safely. Resident #103 sustained a fractured left clavicle and a sprained right foot from a fall when two nurse aides transferred Resident #103 after completion of her dialysis treatment without the use of a total lift. Resident #103 was not cleared by therapy to be transferred manually. The facility also failed to prevent Resident #37 from obtaining skin tears when the nurse aide continued to provide care after the resident became combative and was hitting his arms on the headboard and siderail. This was for 2 of 5 sampled residents reviewed for supervision to prevent accidents (Resident #103, Resident #37).

Inspectors wrote2. Resident #69 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #69 had moderate cognitive impairment. She had range of motion of her upper extremities with no impairment. She used a manual wheelchair. A review of her smoking assessments revealed that Resident #69 was assessed for smoking on 5/31/23, 7/6/23, 10/12/23 and 11/7/23. She was deemed able to smoke safely with supervision. Resident #69 was able to hold, light and use ashtray independently. She was to wear a smoking apron and be supervised. On 4/17/24 at 3:30 PM Resident #69 was observed smoking in the designated smoking area. She was smoking an e-cigarette. Resident #69 was being supervised by staff and had a smoking apron on. On 4/16/24 at 9:05 AM interviewed Resident #69. She was unable to speak and could only shake her head yes or no. [...]

Inspectors wroteBased on observations, record review, and interviews with staff the facility failed to maintain areas used by residents by not repairing bathroom doors with missing and splintered wood surfaces (room [ROOM NUMBER], 215, and 219); failed to repaint scuffed areas on metal door frames (rooms [ROOM NUMBERS]); and failed to repair the footboard of a bed with rough and jagged surface areas (room [ROOM NUMBER]-B) on 2 of 2 units observed for environment (North and South).

Inspectors wroteBased on record review and interviews with the resident, staff, and the Consultant Pharmacist, the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #71).

Inspectors wroteBased on record reviews, and interviews with staff, Hospice Nurse, Physician Assistant, Medical Director and Consultant Pharmacist interviews, the facility failed to limit the duration of a psychotropic medication (a drug that affects brain activities associated with mental processes and behaviors) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate (Resident #94) and failed to monitor for abnormal involuntary movements on a resident receiving an antipsychotic medication (Resident #71) for 2 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interviews, and record reviews, the facility failed to record the opening date for 1 opened insulin, failed to remove 1 expired insulin in 1 of 4 medication carts (Seafoam Hall), and failed to remove expired over the counter (OTC) medications and supplements in accordance with the manufacturer's expiration date for 1 of 4 medication carts (Silver Hall) and 1 of 2 medication storage rooms observed during medication storage checks (South medication storage room).

Inspectors wroteBased on observations and staff interviews the facility failed to clean and maintain the walk-in refrigerator, oil deep fryer area, circulatory fans of the walk-in freezer, and a storage shelf for ready-to-use cookware. This practice had the potential to affect all residents.

Inspectors wroteBased on observations, record reviews, resident, resident representatives, family and staff interviews, and interviews with psychotherapist, Psychiatric Nurse Practitioner, Physician Assistant and the Medical Director, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey conducted on [DATE] and the recertification and complaint investigation survey conducted on [DATE]. This was for repeat deficiencies in the areas of accident hazards/supervision and medication storage that were originally cited on [DATE] during the recertification and complaint investigation survey, and subsequently recited during the recertification and complaint investigation survey completed on [DATE]. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to maintain the two-compartment sink as evidenced by a leaking drainpipe. This had the potential to affect the cleanliness and sanitation of the kitchen.

Inspectors wroteBased on observations, record review, interviews with the resident and staff the facility failed to assess if a cognitively impaired resident had the ability to self-administer eye drops and a medicated cream that was kept at the beside for 1 of 1 resident reviewed for self-administration (Resident #24).

Inspectors wroteBased on record review and staff interviews, the facility failed to file a report with the state agency within 2 hours for an incident of resident-to-resident abuse (Residents #3, #52) and an allegation of employee to resident abuse (Resident# 37). In addition, the facility failed to file a report with the Adult Protective Services (APS) within the required timeframe for Residents #3 and #52 after an allegation of sexual abuse. This deficient practice affected 3 of 12 residents reviewed for abuse (Residents #3, #37, #52).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of behaviors and discharge status for 2 of 13 residents whose MDS were reviewed (Resident #264 and Resident #113).

Inspectors wroteBased on record review, family interview and staff interview Resident #192 was administered the Covid-19 booster vaccination by mistake after her health care power of attorney (HCPOA) had declined the vaccination. This was for 1 of 5 residents reviewed for vaccination status (Resident #192).

Inspectors wroteBased on record review and staff interviews the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #30). On 11/24/2022 while providing care Nurse Aide (NA) #2 rolled Resident #30 over, the resident was being combative, and NA #2 put her leg on Resident #30's upper leg to restrain the resident.

Inspectors wroteBased on record review and staff interviews the facility failed to report to Adult Protective Services (APS) and immediately report to nursing or administration which resulted in a lack of protection for Resident #30 and all residents for 1 of 3 residents (Resident #30). On 11/24/2022 while providing care Nurse Aide (NA) #2 rolled Resident #30 over, the resident was being combative, and NA #2 placed her leg on Resident #30's leg to restrain the resident.