Deer Park Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Deer Park Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Aug 14, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Aug 14, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Aug 14, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Jun 24, 2025

  2. 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. […]

• Immediate jeopardy, isolatedF689Jun 24, 2025

  Based 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. […]