Juniper Gardens Center for Nursing and Rehabilitat

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, and family interviews, the facility failed to ensure residents' rights to maintain dignity for 3 of 3 residents reviewed for dignity (Resident #33, Resident #41, and Resident #24). The findings included: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included chronic pain, muscle weakness, and reduced mobility. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact with no behaviors, had adequate vision and no issues with communicating. The MDS documented Resident #33 was frequently incontinent of urine and bowel and required substantial to max assistance with toileting. On 11/18/25 at 11:56 AM an interview was conducted with Resident #33. She stated there was a night shift (11:00 PM to 7:00 AM) Nurse Aide (NA) #1 who made her lay wet when she was incontinent. Resident #33 stated when she called before first rounds on night shift and informed NA #1 she needed an incontinence change, NA #1 told her, No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and resident interviews the facility failed to ensure advance directive information was accurate throughout the medical record for 1 of 1 resident reviewed for advance directives (Resident #4).The findings included:Resident # 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].Review of Resident #4's electronic health record (EHR) revealed an active physician order dated [DATE] that stated Do Not Resuscitate (DNR).Resident #4's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact.Further review of Resident #4's electronic health record revealed an active physician order dated [DATE] stated that he was a Full Code.Resident #4's advance directive care plan dated [DATE] revealed residents' code status to be Full Code.An observation conducted on [DATE] of the Advance Directives binder located at the nursing station revealed a yellow Do Not Resuscitate form dated [DATE] and indicated no expiration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 4 of 4 residents (Resident #1, #6, #8, and #42) reviewed for respiratory care. The findings included: a. Resident #1 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was not coded for receiving oxygen. A review of Resident #1's physician orders revealed an order dated 1/26/24 for oxygen to be administered continuously via nasal cannula at 3 liters per minute (l/min). An observation on 8/19/24 at 4:03 PM revealed Resident #1 was lying in bed wearing a nasal cannula with oxygen being administered at 3 l/min. There was no cautionary or safety signage posted at the entrance to Resident #1's room to indicate oxygen was in use. An observation of Resident #1 conducted on 8/20/24 at 11:00 AM revealed she was sitting on the side of her bed with oxygen being administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, staff, Consultant Pharmacist, Nurse Practitioner, and Physician interviews, the facility failed to administer medications as ordered by the Physician that included Bosulif (medication for leukemia) and Olanzapine (an antipsychotic medication). This occurred for 2 of 5 residents (Resident #9 and Resident #13) reviewed for significant medication errors. Findings included: 1. Resident #9 was admitted to the facility 08/24/22 with a diagnosis including chronic myelocytic leukemia (cancer of white blood cells). Review of Resident #9's Physician orders revealed an order dated 01/20/23 for Bosulif 100 milligrams (mg) 2 tablets by mouth every day related to leukemia. Review of Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors. Review of Resident #9's Medication Administration Records (MARs) from December 2023 through August 2024 revealed Bosulif was initialed by nursing staff as being administered as ordered. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews the facility failed to implement Special Droplet Contact Precautions when Nurse #1 and Nurse Aide (NA) #1 entered Resident #4's room without donning Personal Protective Equipment (PPE); failed to ensure staff implemented their infection control policy for hand hygiene when Nurse #2 failed to wear gloves during insulin administration and perform hand hygiene after insulin administration for Resident #28; and when Unit Manager #1 failed to perform hand hygiene after removing dirty gloves and before donning clean gloves during wound care for Resident #12. These failures occurred during a COVID-19 outbreak at the facility for 3 of 5 residents reviewed for infection control practices (Resident #4, Resident #28, Resident #12). Findings included: The Special Droplet Contact Precautions (SDCP) signage, with a revised date of 02/09/2022, noted staff should follow the instructions on the signage before entering the resident's room which included, All healthcare personnel must: 1) clean hands before entering and when leaving the room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff, and responsible person (RP) interviews, the facility failed to notify the RP of a follow-up urologist appointment for a scheduled procedure for Resident #19. During Resident #19 urology appointment on 5/31/24, a follow-up recommendation for a cystoscopy (used to diagnose, monitor, and treat conditions affecting the bladder and urethra) procedure was recommended and scheduled for 6/04/24. Resident #19's RP was not notified of the recommendations for the scheduled cystoscopy on 6/04/24. This deficient practice affected 1 of 3 residents reviewed for notification (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses including obstructive and reflex uropathy (blockage preventing urine from draining properly and cause urine to back-up into kidneys), urinary retention, and use of indwelling catheter. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was moderately cognitively impaired and assessed as having an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of urinary catheter (Resident #97), discharge disposition (Resident #43), activities of daily living (Resident #29), and falls (Resident #24) for 4 of 18 residents reviewed for MDS accuracy. The findings included: 1. Resident #97 was admitted to the facility on [DATE] with diagnoses which included hypertension, end stage renal disease and diabetes mellitus. Resident #97 was observed on 04/30/23 at 1:09 PM sitting up in her wheelchair in her room and had an indwelling urinary catheter. Review of Resident #97's admission Minimum Data Set (MDS) assessment dated [DATE], under Section H. Bladder and Bowel, H100 Appliance, the assessment was marked at A. Indwelling catheter due to the resident's urinary catheter. Under Section H300 Urinary Continence, the assessment was marked at 3. Always incontinent (no episodes of continent voiding) instead of 9. Not rated, resident had a catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and record review, the facility failed to ensure leftover food items stored for use in the reach-in freezer were labeled, dated and sealed. The failure occurred in 1 of 3 cold storage units and had the potential to affect food served to residents. The findings included: An observation occurred on 04/30/23 at 12:10 PM with Dietary Aide #1, of the kitchen's reach-in freezer revealed the following leftover food items stored for use: - an opened undated bag half full of frozen chicken tenders - an opened undated bag half full of frozen diced chicken - two opened undated bags three-fourth full of frozen chicken breast - two opened undated bags half full of frozen chicken drumettes and wings An interview conducted with Dietary Aide #1 on 04/30/23 at 12:20 PM revealed all items in the reach in freezer should be sealed and have a label on them with the date the items were opened. An interview conducted with [NAME] #1 on 4/30/23 at 12:25 PM revealed all items in the reach in freezer should be sealed and have a label on them with the date the items were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the complaint investigation survey of 06/23/22 and a recertification survey of 07/14/21. The repeated deficiency was in the area of accuracy of assessments. The facility's continued failure during three Federal surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F-641: Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of urinary catheter (Resident #97), discharge disposition (Resident #43), activities of daily living (Resident #29), falls (Resident #24) and antipsychotic medications (Resident #21) for 5 of 18 residents reviewed for MDS accuracy. During the complaint investigation of 6/23/22 the the facility failed to obtain a resident's weight within 30 days of the Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to ensure a resident had been assessed to self-administer medications (Resident #8). This occurred for 1 out of 3 residents reviewed for medication administration. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD and respiratory failure. Resident #8's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required set up assistance of one staff member for most activities of daily living (ADL). On 05/02/23 at 9:16 AM an observation was conducted of Nurse #1 preparing Resident #8's medication from the medication cart and put them into a cup. Nurse #1 then went into the room with the medication cup and the resident's Cyclosporine (immunosuppressant, used to increase tear production) eye drops. Nurse #1 then handed the medication to Resident #8. Resident #8 stated, I have already administered my eye drops to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, family and staff interviews, the facility failed to provide shaving of resident's face and clipping of toenails for 1 of 4 residents (Resident #40) reviewed for assistance with activities of daily living. The findings included: Resident #40 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included hypertension and non-Alzheimer's dementia. Review of Resident #40's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired and required total assistance of 2 staff with bathing and extensive assistance of 1 staff with personal hygiene and had impairment of both sides of upper and lower extremities. Review of the shower schedule for Resident #40 revealed he received showers on Wednesday and Saturday on 1st shift (7:00 AM to 3:00 PM). Review of Resident #40's care plan dated 03/23/23 revealed a focus area for his inability to complete activities of daily living care related to his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.