Deer Park Health And Rehabilitation

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

emergent situation as emergent. Additional in-service logs were reviewed and revealed all staff (including UM #1 and Nurse #2) were educated on the signs/ symptoms of hypoglycemia, emergent situations, including when to call 911, and notifying the nurse of change in condition. Interviews were conducted with licensed nurses, including agency nurses. The nurses confirmed they had received education on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician when there is a change in resident condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. The licensed nurses were able to accurately verbalize the education they received. Interviews were conducted with licensed nurses, nurse aides, dietary staff, housekeeping, maintenance, office, administration/management, therapy, and agency staff. Interviews were conducted with staff from different shifts. The staff interviews revealed they had received education on the symptoms of hypoglycemia/ hyperglycemia, emergent situations including when to call 911, and notifying the nurse for change of condition. Staff were able to accurately verbalize the education they had received. Review of provider in-service logs revealed on 8/8/25 providers were educated by the Medical Director on the importance of notifying the medical Director when a resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/12/25 was validated.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Deer Park Health and Rehabilitation

306 Deer Park Road Nebo, NC 28761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/13/25 was validated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Deer Park Health and Rehabilitation

306 Deer Park Road Nebo, NC 28761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

open, but she was not alert or responsive. Nurse #4 recalled Resident #1's eyes would move but not like

she was following or focusing on anything. She further recalled her eyes rocking back and forth moving left and right very slowly but she was not moving her head. Nurse #4 said her eyes were not always like that, that sometimes they would just stare straight off and then other times they would move slowly back and forth. Nurse #4 remembered being in Resident #1's room at mealtime, she did not say what meal but said

the NA attempting to assist Resident #1 with her meal stated he could not feed Resident #1 because she would not open her mouth. Nurse #4 reported she told the NA Resident #1 did not look safe to eat. Nurse #4 said as far as she knew Resident #1 did not eat anything that day, she said she was not safe to eat because she was not alert enough. She did not remember the name of the NA. Nurse #4 reported 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. Nurse #4 stated she saw Resident #1 multiple times during her shift, she said she was trying to be helpful and available if she was needed. Nurse #4 stated she remembered Resident #1's blood sugar was in the 30's multiple times during the day. She was not sure about Resident #1's blood sugars from the night shift but remembered during the day shift her blood sugars were in the 30's and 50's multiple times. Nurse #4 stated she thought one time they were able to get Resident #1's blood sugar up to the 70's but then it dropped again. Nurse #4 said her shift ended at 3:00 PM and she left sometime between 3:00 PM and 4:00 PM that day. She recalled hearing Nurse #2 talking to Resident #1's family on the phone right before she left. Nurse #4 stated Resident #1 did not wake up and was non-responsive the entire time. Nurse #4 said 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. She reported she did not remember seeing anything that lo

Event ID:

Facility ID:

If continuation sheet