Gwynedd Healthcare And Rehabilitation Center

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. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and/or when the desired outcome is not met.Review of Resident R3's annual Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident had severe cognitive impairments and diagnoses of dementia (decline in memory or other thinking…

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 review of clinical records and facility documentation it was determined the facility failed to ensure that one resident who displayed and was diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable, mental, and psychosocial well-being that during care for one of 33 residents reviewed (Resident R11). Findings include: Review of Resident R11's clinical record revealed that the resident was admitted to the facility in August 2022, diagnosed with psychological disorders that included unspecified dementia, unspecified severity, with other behavioral disturbances, major depressive disorder, recurrent, severe with psychotic symptoms, unspecified dementia, unspecified severity, with other behavioral disturbances, and delusional disorder. Resident R11 was assessed as cognitively impaired, did not speak English, and spoke through a translator to communicate.Resident R11's care plan dated January 2022 revealed the resident was resistant with care and combative, known to swing arms and throw objects. Nursing…

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 a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to potential resident abuse and/or neglect related to an injury during resident care for one of eight residents reviewed. (resident R 121) Findings include: Review of facility policy titled Reporting and Investigating Resident Accident/ Incident Policy and Procedure reviewed November 2018 revealed that all occurrences which are not consistent with the routine operation of the facility and care of residents that have or may cause physical injury or harm will be reported, reviewed, and investigated. All accidents/ incidents must be reported the supervisor must immediately examine the resident, the appropriate accident incident and investigation report must be completed, the resident's representative and attending physician will be notified, all accidents slash incidents will have an investigation conducted by the supervisor, upon completion of the investigation report…

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 review of facility policies, clinical record reviews, and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person centered care plan related to incontinent care for one of eight residents reviewed.( resident R121) Findings include: Review of facility policy titled Care plans, comprehensive person centered Revealed a comprehensive, persons and our care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care planned interventions are derived from a thorough analysis of the information gathered is a part of the comprehensive assessment. The comprehensive persons care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain them or maintain the residents highest practical physical mental and psychosocial well-being, includes the residents' dated goals, builds on the resident strengths, and reflects currently recognized standards of practice for…

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, review of facility policies and interviews with staff, it was determined that the facility failed to store, food in accordance with professional standards for food service safety. Findings include: Review of facility policy on Receiving revealed that under section Policy Statement, Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery and subsequent storage of all food. Under section Procedures #5 All food items will be appropriately labelled and dated either through manufacturer packaging or staff notation. #8. The Dining Services Director is responsible for following distributor instructions for all applicable products Observation of the kitchen conducted on November 12, 2024, at 9:09 am with the Director of Dietary, Employee E3 revealed the following: One plastic bag containing hamburger buns had a sticker with date delivered of 10/13. Further best by date was not written on the sticker. One plastic bag containing hamburger buns was not labelled with date delivered and was not labelled with best by…

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 clinical record reviews, interviews with staff, reviews of hospital records and facility policies and procedures, it was determined that the facility failed to permit one of four residents to return to the facility after they were hospitalized . (Resident R1) Findings include: Review of the undated policy titled readmission to the facility revealed that it was the responsibility of the administrator and the director of nursing to ensure that all residents who have been discharge from the facility would be readmitted to the facility regardless of race, color, creed, national origin or payment source. Review of the undated policy titled Coronavirus Disease-identification and management revealed that it was the responsibility of the facility to follow the Centers for Disease Control and Prevention guidelines for screening, monitoring, rapid identification and management of this virus. The policy indicated that information about residents being transferred to the facility with suspected or confirmed cases of SARS-CoV-2 infection would be clearly communicated to the facility by…

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 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. and 12:30 p.m., on January 22, 2024, of the main kitchen, of the food and nutrition department, where foods and beverages are stored, prepared and served for the residents revealed that procedures were not being followed in the food preparation and servining process to reduce, eliminate or prevent the possiblity of a…

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 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. Resident R98 stated that foods and coffee were served too cold. Observation during the luncheon meal on January 22, 2024, at 12:52 p.m. Resident R98 stated that his lunch tray was cold and that it could be served warmer. During a group meeting with residents on January 24, 2024, at 10:30 a.m. Resident R6 stated that her breakfast was served cold. Obsservations inside the main kitchen on January 23, 2024, of the…

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, staff interview, and review of clinical records, it was determined tha the facility failed to accommodate the call bell needs of one of 34 residents reviewed (Resident R140). Findings include: Resident R140 was admitted to the facility on [DATE],with the diagnosis of hemiplegia (one sided paralysis) following cerebral infarction (stroke) affecting the left-dominant side and heart failure (heart does not pump sufficiently). Review of Resident R140's care plan revealed pain and general discomfort dated July 11, 2023, interventions included to assist the resident to a position or comfort using pillows or appropriate positioning devices and to place the resident's call bell within resident's reach. On January 22, 2023, at 1:15 p.m. during an interview Resident R140 stated he was very uncomfortable and his whole body hurt. He wanted to recline his head back in bed but couldn't. The television was too loud but could not reach the remote. He explained that his left side didn't work anymore…

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 clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan for edema for one of 34 residents reviewed (Resident R140). Findings include: Resident R140 was admitted to the facility on [DATE], witht the diagnoses of hemiplegia (one sided paralysis) following cerebral infarction (stroke) affecting the left-dominant side and heart failure (heart does not pump sufficiently). Review of Resident R140's care plan revealed pain and general discomfort dated July 11, 2023, interventions included to assist the resident to a position or comfort using pillows or appropriate positioning devices and to place the resident's call bell within resident's reach. On January 22, 2023, at 1:15 p.m. during an interview Resident R140 stated he was very uncomfortable and his whole body hurt. He explained that his left side didn't work anymore because of a stroke. Part of his left lower arm was wrapped in gauze and the rest of his arm was swollen and red…

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, review of resident's clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure physician's wound care recommendations to prevent pressure injuries were followed for one of four residents reviewed with pressure ulcers (Resident R150). Findings include: Review of the facility's policy titled Wound Prevention and Management, not dated, stated that each resident receives the care and services necessary to retain or regain optimal skin integrity. Residents identified as a risk for development of pressure ulcers will have a plan and interventions included in the care plan to address risk factors for development of pressure ulcers. Orders/changes to the treatment will be documented and the care plan will be updated to aide in healing and prevent further breakdown based upon the co-morbidities and the risk factors associated with the resident. Implementation of relevant treatment and preventative measures will be implemented should…

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 a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the failure to provide appropriate assistance during incontinence care to Resident R215, resulting in the resident rolling off the bed and sustaining serious head injuries, which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator revealed, The Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Review of the job description for the Director of Nursing revealed that the primary purpose of the position, is 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.

Based on reviews of facility policies and procedures, observations of the main kitchen of the food and nutrition department, the garbage and refuse area and the pest control operators reports, it was determined that the facility failed to maintain an effective pest control program so that the interior of the building was pest free. Findings include: A review of the policy titled Pest Control dated May, 2008 revealed that it was the responsibility of the facility to ensure that the facility was free of insects and rodents by having an effective pest control program. The policy also indicated that garbage was not permitted to accumulate on the premises. Observations of the hall way outside the food and nutrition department revealed that the threshold of the double doors, upon closing were not sealed properly. When opened, the doors lead directly outside the building, onto the loading dock. Observations at the threshold of the double doors upon closing evidenced a two inch gap. This opening located at the bottom of the doors allowed easy access into the building for common household…

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.