Juniper Gardens Center for Nursing and Rehabilitat

In the surveyor’s words

From the most serious findings on record at Juniper Gardens Center for Nursing and Rehabilitat, in the surveyor’s own words.

• Immediate jeopardy, patternF580Jun 23, 2022

  Based on record reviews, and interviews with staff, and Medical Director, the facility failed to notify the Primary Care Provider of significant changes in a resident's condition (Resident #9) when he developed a new opened sacral pressure ulcer, when the pressure ulcer deteriorated and when he continued to have [CONDITION(S)] (low blood pressure) despite receiving intravenous fluids. The facility also failed to report results of a urinalysis and urine culture resulting in a delay in treating the resident (Resident #9) for [CONDITION(S)] (urinary tract infection). Resident #9 was hospitalized on [DATE] for severe [CONDITION(S)]/septic shock due to an infected stage 4 pressure ulcer to the sacrum. […]

• Immediate jeopardy, patternF684Jun 23, 2022

  Based on record reviews, and interviews with staff, family member, Physician Assistant and Medical Director, the facility failed to identify the seriousness of significant changes in a resident's condition (Resident #9), complete and document on-going thorough assessments and identify the need for medical attention when the resident's medical condition continued to deteriorate. This resulted in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure was for 1 of 3 residents reviewed for quality of care (Resident #9). Immediate Jeopardy began on 3/26/22 when the facility failed to follow up on Resident #9's urine culture results and provide the care and services required by Resident #9 resulting in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, patternF686Jun 23, 2022

  Based on observations, record reviews, and interviews with staff, Wound Physician, Physician Assistant, and Medical Director, the facility failed to complete skin assessments as ordered, effectively assess, and monitor a pressure ulcer, and ensure treatments/interventions were implemented and modified/adjusted according to resident's response (Resident #9). Resident #9 who was at high risk for pressure ulcers was hospitalized on [DATE] with an infected stage 4 pressure ulcer (full-thickness skin and tissue loss) with tunneling (passageway of tissue destruction under the skin surface). In addition, the facility failed to update physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, patternF692Jun 23, 2022

  Based on staff interviews and record reviews, the facility failed to monitor a resident's weight on a weekly basis as ordered by the physician, identify a severe unintended decline in his weight, and implement/adjust interventions. The resident was sent to the hospital on 4/7/2022 and had a feeding tube placed in the stomach for 1 of 1 resident (Resident #10) reviewed for maintain nutritional status. The facility also failed to provide a physician ordered nutritional supplement for 2 of 2 sample residents (Resident #11 and Resident #2). Immediate Jeopardy began on 3/9/2022 when staff failed to identify a significant weight loss of 11.5% for Resident #10. Resident #10 continued to lose weight and had a cumulative weight loss of 24.4% since 1/19/2022. […]

• Immediate jeopardy, patternF835Jun 23, 2022

  Based on record reviews, and interviews with staff, family member, Physician Assistant and Medical Director, the facility failed to provide effective leadership and implement effective systems to manage unintended weight loss, change in condition, physician notification and pressure ulcers. This failure affected 5 of 5 residents reviewed for administration (Resident #2, Resident #6, Resident #9, Resident #10, and Resident #11). Immediate Jeopardy began on 3/9/2022 when when effective systems were not in place to ensure residents received necessary care and services. Immediate Jeopardy was removed as of 6/18/2022 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. […]