Federal inspectors determined the incident at Deer Park Health and Rehabilitation posed immediate jeopardy to resident health and safety during a complaint investigation completed in August.
Nurse #4 arrived for her day shift to find Resident #1 with her eyes open but completely unalert and unresponsive. The resident's eyes would move slowly back and forth, left to right, without focusing on anything. Sometimes they would just stare straight ahead.
"Her eyes were not always like that," Nurse #4 told inspectors. "Sometimes they would just stare straight off and then other times they would move slowly back and forth."
The nurse said Resident #1 was not moving her head, just her eyes in that slow, unfocused pattern.
At mealtime, a nursing assistant attempted to help Resident #1 eat but told Nurse #4 he couldn't feed her because she wouldn't open her mouth. The nurse looked at the resident and made a critical assessment.
"Resident #1 did not look safe to eat," Nurse #4 reported telling the nursing assistant.
As far as she knew, Resident #1 didn't eat anything that entire day. The nurse said the resident wasn't alert enough to safely consume food.
Meanwhile, Resident #1's blood sugar levels plummeted to dangerous levels throughout the day shift. Nurse #4 remembered the readings were "in the 30's multiple times during the day." Normal blood sugar levels typically range from 80 to 130 mg/dL before meals.
The blood sugar readings fluctuated wildly. Nurse #4 recalled seeing levels in both the 30s and 50s multiple times during her shift. At one point, staff managed to get Resident #1's blood sugar up to the 70s, but it dropped again.
Nurse #4 said she wasn't sure about the resident's blood sugar levels from the previous night shift, but the dangerous readings continued throughout the day.
Concerned about what she was witnessing, Nurse #4 made frequent trips to check on Resident #1. She was "in and out of Resident #1's room during her shift just checking on her because she was concerned and curious about what was going on."
The nurse said she saw Resident #1 multiple times during her shift, trying to be helpful and available if needed.
But nothing changed. Resident #1 remained in the same unresponsive state from morning until the end of the day shift.
"Resident #1 did not wake up and was non-responsive the entire time," Nurse #4 told inspectors. "Resident #1 was pretty much the same from the time she got there in the morning until she left at the end of her shift that day."
As Nurse #4's shift ended between 3:00 PM and 4:00 PM, she heard Nurse #2 talking to Resident #1's family on the phone right before she left the facility.
The inspection report indicates this case involved immediate jeopardy violations affecting few residents. Federal regulations require nursing homes to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Dangerously low blood sugar, known as severe hypoglycemia, can cause confusion, seizures, loss of consciousness and even death if left untreated. Blood sugar levels in the 30s represent a medical emergency requiring immediate intervention.
The facility's handling of Resident #1's condition raised serious questions about medical monitoring, emergency response protocols and basic nursing care standards during the day shift when multiple staff members observed the resident's deteriorating condition.
Federal inspectors documented the violations as part of a complaint investigation, suggesting someone reported concerns about the facility's care practices to state health officials who then conducted the unannounced inspection in August.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deer Park Health and Rehabilitation from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Deer Park Health and Rehabilitation
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