Gwynedd Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Gwynedd Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 26, 2024

  Based on review of professional literature, review of facility documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide appropriate assistance while providing incontinence care to a resident, resulting in the resident rolling off the bed and sustaining serious head injuries, including an acute right subdural hemorrhage, left diffuse subdural hematoma, right-to-left midline shift and right uncal herniation and subsequence death. This resulted in an Immediate Jeopardy situation for Resident R215, one of six residents reviewed related to falls. […]

• Actual harm, isolatedF689Dec 4, 2025

  Based on interviews, review of clinical records, facility documentation, and policy it was determined the facility failed to ensure Resident R109 was provided with the necessary equipment of wheelchair leg rest to ensure safety and proper positioning during transportation to an outside appointment. This failure resulted in actual harm to Resident R109 who while being wheeled out of the transportation van fell face forward from the wheelchair and sustained a right femur fracture for one of 33 residents reviewed (Resident R109). […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2024

  Based on observations of the Food and Nutrition Services Department, reviews of policies and procedures and interviews with staff, it was determined that foods and fluids were not being stored, prepared, delivered and served under sanitary conditions to meet professional standards of food service safety. Findings include: A review of the policies titled sanitizing food surfaces and equipment cleaning dated October 2022, revealed that it was the responsibility of the dietary staff to ensure that food contact surfaces were maintained clean and sanitary in the main kitchen. The policies also indicated that dietary staff were also responsible for maintaining all food service equipment clean and sanitary to prevent a food safety hazard. Observations made between 9:00 a.m. […]

• No harm, potential for more than minimal, patternF804Jan 26, 2024

  Based on interviews with residents and staff and observations of the food and nutrition services, a meal tray evaluation and reviews of facility policies and procedures, it was determined that the facility failed to ensure that foods were served palatable and at proper temperature (Residents R6, R14 and R98). Findings include: Areview of the facility policy titled Test Tray Evaluation dated January, 2023 revealed that the acceptable temperature for the foods at point of service to the residents was 135 degrees Fahrenheit. Interview on January 22, 2024, at 10:58 a.m. Resident R14 stated that sometimes the food was served cold. Interview on January 22, 2024, at 11:08 a.m. […]

• No harm, potential for more than minimal, isolatedF657Dec 4, 2025

  Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to review and revise a resident care plan with new interventions status post a fall for one of 33 residents reviewed (Resident R3). Findings include: Review of facility policy Care plans, Comprehensive Person-Centered revised March 2022, revealed a comprehensive, person-centered care plan that includes measurable objectives to meet the resident's needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the residents' conditions changes. […]