Juniper Gardens Center for Nursing and Rehabilitat

Inspectors wroteBased on record review, and resident, staff, and family interviews, the facility failed to ensure residents' rights to maintain dignity for 3 of 3 residents reviewed for dignity (Resident #33, Resident #41, and Resident #24).

Inspectors wroteBased on observations, record review, staff and resident interviews the facility failed to ensure advance directive information was accurate throughout the medical record for 1 of 1 resident reviewed for advance directives (Resident #4).

Inspectors wroteBased on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email) and telephone numbers of all required state agencies and advocacy groups, such as the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program and the resident advocacy network. These observations occurred on 3 of the 4 days of the onsite recertification survey.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to display survey results in a location accessible to residents and the public. This deficient practice occurred for 4 out of 4 days of the survey.

Inspectors wroteBased on record review, resident, staff, physician and contract transport company interviews, the facility's contracted transport driver (Driver #1) failed to leave Resident #12 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #12 was being transported back from a medical appointment in a contract transport van while unsecured in her wheelchair. Driver #1 made a sudden stop which caused Resident #12 to fall forward out of her wheelchair onto the van floor. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if the resident sustained any injuries. Upon arrival at the facility, Driver #1 did not notify facility staff of the resident's fall. [...]

Inspectors wroteBased on record review and interviews with resident, staff, physician and the contract transport company's owner, the facility's contracted transport driver (Driver #1) failed to provide safe transportation when Resident #12's lap belt was not applied leaving her unsecured in her wheelchair. Resident #12 was being transported back from a medical appointment when Driver #1 made a sudden stop resulting in Resident #12 falling forward out of her wheelchair onto the van floor on her left knee and rolling onto her left side. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Resident #12 had swelling and a skin tear to her left knee. [...]

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 4 of 4 residents (Resident #1, #6, #8, and #42) reviewed for respiratory care.

Inspectors wroteBased on record review, resident, staff, Consultant Pharmacist, Nurse Practitioner, and Physician interviews, the facility failed to administer medications as ordered by the Physician that included Bosulif (medication for leukemia) and Olanzapine (an antipsychotic medication). This occurred for 2 of 5 residents (Resident #9 and Resident #13) reviewed for significant medication errors.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement Special Droplet Contact Precautions when Nurse #1 and Nurse Aide (NA) #1 entered Resident #4's room without donning Personal Protective Equipment (PPE); failed to ensure staff implemented their infection control policy for hand hygiene when Nurse #2 failed to wear gloves during insulin administration and perform hand hygiene after insulin administration for Resident #28; and when Unit Manager #1 failed to perform hand hygiene after removing dirty gloves and before donning clean gloves during wound care for Resident #12. These failures occurred during a COVID-19 outbreak at the facility for 3 of 5 residents reviewed for infection control practices (Resident #4, Resident #28, Resident #12).

Inspectors wroteBased on record reviews, staff, and responsible person (RP) interviews, the facility failed to notify the RP of a follow-up urologist appointment for a scheduled procedure for Resident #19. During Resident #19 urology appointment on 5/31/24, a follow-up recommendation for a cystoscopy (used to diagnose, monitor, and treat conditions affecting the bladder and urethra) procedure was recommended and scheduled for 6/04/24. Resident #19's RP was not notified of the recommendations for the scheduled cystoscopy on 6/04/24. This deficient practice affected 1 of 3 residents reviewed for notification (Resident #19).

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set assessment (MDS) for oxygen use (Resident #1, #6, and #8) and hospice services (Resident #1 and Resident #4) for 4 of 5 residents reviewed for accuracy of assessments.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to administer pain medication to 1 of 1 resident (Resident #97) reviewed for pain management when she complained of pain at a level of 9 on a scale of 0 to 10.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of urinary catheter (Resident #97), discharge disposition (Resident #43), activities of daily living (Resident #29), and falls (Resident #24) for 4 of 18 residents reviewed for MDS accuracy.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure leftover food items stored for use in the reach-in freezer were labeled, dated and sealed. The failure occurred in 1 of 3 cold storage units and had the potential to affect food served to residents.

Inspectors wroteBased on record reviews, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the complaint investigation survey of 06/23/22 and a recertification survey of 07/14/21. The repeated deficiency was in the area of accuracy of assessments. The facility's continued failure during three Federal surveys showed a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure a resident had been assessed to self-administer medications (Resident #8). This occurred for 1 out of 3 residents reviewed for medication administration.

Inspectors wroteBased on observations, record review, family and staff interviews, the facility failed to provide shaving of resident's face and clipping of toenails for 1 of 4 residents (Resident #40) reviewed for assistance with activities of daily living.