Double Tree Post Acute Care Center

In the surveyor’s words

From the most serious findings on record at Double Tree Post Acute Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 3, 2024

  Based on observation, interview and record review, the facility failed to properly manage a resident's Type 2 Diabetes Mellitus (DM2-a disease that results in too much glucose, also called blood sugar in the blood) for one of 28 sampled residents (Resident 31) when the Licensed Nurses (LN) did not follow Physician Orders and the standards of care for diabetes. These failures resulted in Resident 31 having dangerously high levels of glucose throughout the day and suffering from unwanted symptoms of hyperglycemia (high sugar level) which could have led to a diabetic coma, a life-threatening medical emergency requiring immediate medical care or death if left untreated. Findings: An Immediate Jeopardy (IJ) situation was declared at 7:25 p.m. […]

• Actual harm, isolatedF692Oct 12, 2022

  Based on interview and record review, the facility failed to maintain, for Resident 1, a therapeutic: 1. hydration status, and 2. nutritional status, when Resident 1 was admitted to the acute hospital with critical lab values and significant weight loss (unintentional loss of 5% or more of normal body weight) occurring over a 15-day period. This failure resulted in Resident 1 experiencing avoidable physical harm which required transfer to a higher level of care. Findings: Resident 1 was admitted to the facility in early 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, interview and record review, the facility failed to ensure industry standards for food safety were met for a resident population of 102, when: Kitchen walls had chipped paint and damaged dry walls, food shelves were rusty, vents over food production area were rusty, floor tiles were chipped, and linoleum tiles had dark discoloration and rust stains making it difficult to determine if clean and sanitary;Spices were labeled using inconsistent use by dating system and one spice had expired;Plastic containers and lids were stacked and stored while wet in ready-to-use area; A metal colander was observed with dried food inside the openings and along the base, a plastic scoop had food residue inside its bowl, and a knife case had dust and crumbs all along the top near… […]

• No harm, potential for more than minimal, widespreadF925Aug 17, 2023

  Based on observation, interview and record review, the facility failed to ensure an effective pest control program was provided for a census of 109, when roaches, ants and flies were found in multiple locations throughout the building. This failure resulted in the presence of pests inside the facility and had the potential to result in the transmission and spread of infection. Findings: During a review of the facility's (Name of Company .PEST MANAGEMENT) Service Summary Report (SSR) dated 4/28/23, the SSR indicated, Services & Findings: Inspected interior rooms 600, 608 and 609 checked monitors for roaches. […]

• No harm, potential for more than minimal, patternF804Jan 23, 2026

  Based on observation, interview and record review, the pureed and alternate foods made for lunch on 1/21/26 were not made by methods that conserved nutritive value, flavor and appearance when recipes were not utilized. This failure had the potential to lead to poor intake, weight loss and malnutrition for the 6 residents eating the chicken entree and 10 residents (Residents 2, 14, 16, 24, 42, 52, 63, 71, 90 & 95) receiving the pureed pot roast and pureed peas.Findings: During a return visit to the kitchen on 1/21/2026 at 9:42 a.m., [NAME] 1 (Ck 1) was preparing the lunch meal. The main meal consisted of pot roast and roasted potatoes which had been prepared and were in the oven. The alternative entree was Lemon Almond Chicken. […]