Premier Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF684Jun 30, 2022

  Based on record review and interviews with staff, Speech Therapist, Nurse Practitioner and Physician the facility failed to review a history and physical from the hospital for a newly admitted resident, administer diabetes medications as listed on the hospital discharge summary, clarify medication orders with the physician, and monitor blood sugars for a resident with diabetes. Resident #3 was unresponsive to verbal stimuli on 5/25/22 and required hospitalization in the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 2 residents (Resident #3) reviewed for diabetes care. […]

• Immediate jeopardy, patternF835Jun 30, 2022

  Based on record review and interviews with the Physician, Nurse Practitioner, Speech Therapist, and staff, the facility Administration failed to provide leadership and oversight to ensure effective systems were in place for reviewing history and physicals from the hospital for newly admitted residents, administering diabetes medications as listed on the hospital discharge summary, clarifying medication orders with the physician, monitoring blood sugars for a resident with diabetes, and acting upon recommendations contained in the Consultant Pharmacist ' s new admission Medication Regimen Review (MRR) for 1 of 2 residents (Resident #3) reviewed for diabetes care. […]

• Immediate jeopardy, isolatedF756Jun 30, 2022

  Based on record review and interviews with staff and the physician, the facility failed to act upon the consultant pharmacist's new admission Medication Regimen Review (MRR) that identified [MEDICATION(S)] (a medication used in the treatment of diabetes) 1000 milligrams twice daily listed on the hospital discharge summary was omitted from the facility's physician orders resulting in 12 missed doses of the medication for 1 of 2 residents reviewed for diabetes care (Resident #3). Resident #3 was unresponsive to verbal stimuli on 5/25/22 at 09:30 AM. Resident #3 was cool and clammy to touch with a blood sugar of Hi, indicating an abnormal reading with a level greater than 400 milligrams per deciliter. […]

• Immediate jeopardy, isolatedF925Jun 30, 2022

  Based on record review and interviews with facility staff, Medical Director, Nurse Practitioner, and Vascular Surgeon, the facility failed to maintain an effective pest control system resulting in maggot infestation of a resident's wound for 1 of 2 residents wounds (Resident #1) reviewed for pest control. Resident #1 was discharged to the emergency room (ER) on 6/12/22 with respiratory distress. He presented to the hospital with [CONDITION(S)] (a life-threatening complication of an infection) criteria with fever, [CONDITION(S)] (pulse over 100), and some altered mental status. When Resident #1's dressings were removed, and the wounds inspected, the left heel was infested with maggots. […]

• Actual harm, isolatedF600Mar 27, 2024

  Based on record review, staff, and Psychiatric Nurse Practitioner interviews, the facility failed to protect 2 of 5 residents' rights to be free from physical abuse (Residents #114 and #29). All residents involved resided in the memory care unit. Resident #99 struck the back of Resident #114's head on 9/8/23 and hit Resident #114's left jaw twice on 10/11/23. Both incidents occurred after Resident #114 wandered into Resident #99's room. Resident #114 had redness and a small amount of swelling to the left side of face after the second incident. Resident #99 slapped Resident #29 on the cheek after Resident #29 touched Resident #99's pants in the activity room. Resident #29 sustained no injuries. […]