Apple Rehab Avon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and review of the facility policy for the only resident reviewed for dialysis (Resident #8), the facility failed to ensure that a resident on dialysis and with a fluid restriction had fluid intake consistently monitored and documented as per facility policy. The findings include: Resident #8's diagnoses included end-stage renal disease and dependence on renal dialysis.A physician order dated 6/13/25 directed a 1500 milliliter (ml) fluid restriction.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was severely cognitively impaired, required partial/moderate assistance with oral hygiene and was dependent for toilet and personal hygiene. The MDS further identified Resident #8 was receiving dialysis since admission.A hydration risk assessment dated [DATE] identified that Resident #8 was on fluid restrictions and that intake and output (I&O's) had been initiated for at least 72 hours. A physician order dated 8/1/25 directed a 1500 ml…

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 review of the clinical record, facility documents, interviews and facility policy for 1 of 5 residents (Resident #32) reviewed for unnecessary medication, the facility failed to ensure facility staff/pharmacy completed monthly medication reviews for 3 months. The findings include: Resident #32's diagnosis included Type 2 diabetes, depression, anxiety anemia hypothyroidism, hypertension and bipolar disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 received insulin injections, antidepressants, antianxiety medication, anticonvulsant medication, and hypoglycemic medications. The Resident Care Plan (RCP) dated 11/13/24 indicated Resident #32 was at risk for adverse effects of hypothyroidism with interventions that included to provide medication and obtain lab work as ordered while observing for adverse signs and symptoms. The RCP also indicated Resident #32 was at risk for complications related to diabetes and the risk for low or elevated blood sugar levels.…

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, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include:Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include: Resident #1's diagnoses included panniculectomy (removal of excess fat/skin in lower abdomen) during 2024, infection following surgical procedure and wound dehiscence (reopened). Physician order dated 7/7/2025 directed to change wound vac dressing three (3) times per week on Monday, Wednesday and Friday. The Resident Care…

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 reviews, review of facility documentation, facility policies, and interviews for one (1) of three (3) sampled residents (Resident #3) who were required supervision during meals, the facility failed to follow the physician's order and provide the one to one (1:1) supervision when food was delivered to Resident #3 to prevent a choking episode. The findings include: Resident #3's diagnoses included bipolar disorder, diabetes mellitus, asthma, depression and anxiety. The initial Resident Care Plan dated 2/7/25 identified non-compliance related to diet, drinking thin liquids when on a nectar thick liquid diet. Interventions directed to educate the resident on the importance of following the physician's order while respecting resident rights and observing any untoward effects of non-compliance, document and report to the provider. The admission Minimum Data Set assessment dated [DATE] identified Resident #3 had no memory recall deficits and required supervision with eating. The speech therapy…

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, facility documentation, facility policy and interviews for one of three residents (Resident #6) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse. The findings include: Resident #6 was admitted with diagnoses that included borderline personality, post-traumatic stress disorder. A resident care plan (RCP) dated 7/25/2024 identified Resident #6 exhibited accusatory behaviors and poor impulse control towards staff's care. Interventions directed to approach in a clam manner, explain all procedures and medications before administering and do not engage if resident escalates or becomes accusatory. A quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS of 15 meaning he/she was alert and oriented, and was independent with ALDs and mobility. A facility grievance form dated 8/25/2024 identified Resident #6 reported that the weekend supervisor had recorded her/him on his cell phone saying Resident #6 had…

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, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for grievances, the facility failed to ensure interventions were put into place timely to prevent a wandering resident from entering another resident room. The findings include: Resident #1 had a diagnosis of dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment and used a wheelchair. The Resident Care Plan (RCP) dated 2/29/2024 identified Resident #1 had wandering behaviors. Interventions directed to redirect and engage in activities. Record review identified Resident #1 was self-mobile in a wheelchair. Resident #2's diagnoses included panic disorder, anxiety, and post-traumatic stress disorder (PTSD). The quarterly MDS assessment dated [DATE] identified Resident #2 as alert and oriented and was independent with ADL care. The RCP dated 2/17/2024 identified PTSD, anxiety, and panic disorder. Interventions directed 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 review of the clinical record, facility documentation, facility policy, and interviews for 4 of 4 residents (Resident #20, #36, #202, and #302) reviewed for accidents, the facility failed to ensure the baseline care plan was completed in a timely manner. The findings include: 1. Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and diabetes type 2. The admission MDS assessment dated [DATE] identified Resident #20 had intact cognition, spinal stenosis, lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 had 2 care plans, one from dietary with a focus on obesity, not following diet at home, and the Activities Director with a focus on orientating to the facility with interventions that included a controlled carbohydrate diet, one to one visits and activities calendar activities introduced respectively. An interview with the DNS on 2/27/24 at 10:00AM identified it is her expectation that baseline care plans are…

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 review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #25, #39 and Resident #202) reviewed for care planning,the facility failed to ensure quarterly care plan meetings were conducted, the facility failed to update the care plan reflecting the resident's preferences for provision of care and accusatory behaviors and the facility failed to revise the comprehensive care plan after falls. The findings include: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses which included COPD, atrial fibrillation, and hypertension. The resident care plan sign-in sheet identified care plan meetings with the IDT(inter discilplinary team ) , Resident #25, and his/her Resident Representative occurred on 5/20/22, 8/29/22, and 4/7/23. The quarterly MDS assessment dated [DATE] identified Resident #25's cognition was not assessed and was independent with personal hygiene, eating, and walking. The care plan dated 12/6/23 identified Resident #25…

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 review of facility documentation, facility policy, and interviews, the facility failed to ensure all licensed nurses( 27 ) were certified and had up to date Cardiopulmonary Resuscitation (CPR) cards. The findings include: Review of the facility licensed nurses identified there is a total of 27 licensed nurses on staff (16 Registered Nurses and 11 Licensed Practical Nurses). Review of the CPR binder for licensed nurses identified 19 licensed nurses failed to have valid and up to date CPR cards. The facility had 8 out of 27 licensed nurses with valid and up to date CPR cards on file. Interview and facility documentation review with LPN #1 on [DATE] at 12:00 PM identified she has been employed by the facility since [DATE] as the Infection Preventionist, Staff Development, and Wound Nurse. LPN #1 indicated she had reviewed all licensed nurses CPR cards and was aware that 19 licensed nurses did not have valid and up to date CPR cards on file. LPN #1 indicated she had notified the DNS, Administrator, and RN…

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 the facility documentation and interviews, the facility failed to ensure 18 of 27 licensed nurses completed annual competencies related to providing Intravenous Therapy (IV) and the facility failed to ensure 14 of 27 licensed nurses had Intravenous Therapy (IV) certificates. The findings include: Review of the State Agency documentation identified the facility has a licensed bed capacity of 60 and an IV therapy program. 1. Review of the facility licensed nurses identified there is a total of 27 licensed nurses on staff (16 Registered Nurses and 11 Licensed Practical Nurses). Interview with LPN #1 on 2/26/24 at 9:15 AM identified she has been employed by the facility since 12/13/23 as the Infection Preventionist (IP), Staff Development, and the wound nurse with oversight from the DNS. Interview and facility documentation review with LPN #1 on 2/26/24 at 11:00 AM identified she was not aware that all licensed staff did not complete IV competencies for the year 2023. LPN #1 and the DNS indicated they were able to locate 9 out of 27 licensed nurse's competencies 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 review of facility documents, review of facility policy and interviews, the facility failed to complete performance reviews for 3 of 4 of the nurse aide personnel files reviewed every 12 months as required. The findings include: Facility document review of 4 NA personnel files identified the following: NA #3 personnel file identified she was hired in 2017 and no performance reviews were completed for years 2022 and 2023. NA #4 personnel filed identified he was hired in 2018 and no performance reviews were completed for years 2022 and 2023. NA #5 personnel file identified she was hired in 2013 and performance reviews were completed for year 4/15/23 (An exception rating was identified in 4 categories) no evaluation was completed for 2020, 2021, 2022. NA #6 personnel file identified she was hired 2019 and no performances reviews were completed for years 2020, 2021, 2022, and 2023. Interview on 2/27/24 at 10:00AM with the DNS and Administrator identified they are aware performance reviews were not completed for 2023. The Administrator identified that she is implementing a plan…

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 review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #21, Resident #352, Resident #4 and Resident #28) reviewed for unnecessary medications, the facility failed to ensure the narcotic destruction was performed per facility policy and the facility failed to ensure medications were not left at the bedside unsecure. The findings include: Resident #21 was admitted to the facility with diagnoses which included cancer, chronic pain, and diabetes. The care plan dated 7/12/23 identifies Resident #21 has moderate to severe pain. Interventions included medications as ordered by the physician. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition and pain were not completed. 1. A physician's order dated 11/24/23 directed to apply 2 Fentanyl transdermal patch 100 mcg/hour and one Fentanyl 25 mcg/hour patch for a total of 225mcg/hour apply 3 patches transdermal every 72 hours for pain management and remove per schedule. A review…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #18 and #302) reviewed for dignity, the facility failed to ensure resident was treated in a dignified manner and to ensure that the resident's rights related to personal hygiene were honored. The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included dementia, urinary tract infections, right femur fracture and falls. A physician's order dated 1/30/24 directed to administer Lasix 20 mg every morning. The admission MDS assessment dated [DATE] identified Resident #18 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required total assistance with dressing, toileting, and personal hygiene. Additionally, had no behavior. The February 2024 care plan identified Resident #18 needs assistance for activities of daily living. Interventions included assisting as needed to meet toileting needs and…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #35) reviewed for care planning, the facility failed to invite the resident/resident representative to participate in the care plan meetings. The findings include: Resident #35 was admitted to the facility in January 2023 with diagnoses which included transient ischemic attack (TIA), cerebral infarction, epilepsy, and dementia with psychotic disturbance. Review of the clinical record identified Resident #35 had an admission MDS dated [DATE], quarterly MDS dated [DATE], quarterly MDS dated [DATE], quarterly MDS dated [DATE], annual MDS dated [DATE], and a quarterly MDS dated [DATE]. The quarterly MDS assessment dated [DATE] identified Resident #35 had severely impaired cognition and required extensive assistance with bed mobility. Interview with Person #1 (Resident #35's representative) on 2/25/24 at 8:54 AM identified Resident #35 has been a resident at the facility since January 2023.…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #21) reviewed for choices, the facility failed to ensure resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. The findings include: Resident #21 was admitted to the facility with diagnoses that included cancer, chronic pain, diabetes, and sleep apnea. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition was not completed and required no assistance with dressing and personal hygiene. The care plan (not dated) identifies Resident #21 requiresassist as need with toileting needs and if he/she declines a shower provide a full bed bath and honor his/her wishes. The Resident Care Card dated 1/11/24 identified Resident #21 was scheduled for a shower on Thursdays on the 7:00 AM -3:00 PM shift and required total assistance. A physician's order dated 11/24/23 directed to give a shower weekly on Thursdays…

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, clinical record review, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #36 and Resident #302) reviewed for advanced directives, the facility failed to ensure that advance directives were reviewed and obtained from the resident and/or resident representative. The findings include: 1. Resident #36 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrotomy, and diabetes. The admission MDS assessment dated [DATE] identified Resident #36 had intact cognition, was always incontinent of bowel and bladder, and was fully dependent on staff for toileting, dressing, and bathing. The care plan dated [DATE] identified Resident #36 required assistance with ADLs. Interventions included advance directives per physician's orders. Review of the clinical record failed to identify any documentation or physician's orders related to advance directives for Resident #36. Interview with Resident # 36 on [DATE] at 8:36 AM identified…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #202) reviewed for medications, the facility failed to update the physician and resident representative of refusal of medications and new orders for medications in a timely manner. The findings include: Resident #202 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, cardiovascular disease, and diabetes. A physician's order dated 2/17/24 directed to administer Lispro insulin 3 units before meals, Olanzapine 2.5 mg twice a day, and Acetaminophen 975 mg three times a day. The nurse's note dated 2/17/24 at 5:04 AM identified Resident #202 was admitted to facility on 2/16/24 at 8:00 PM and was alert but confused and behavioral disturbances. The nurse's note dated 2/17/24 at 3:20 PM identified Resident #202 was alert with intermittent confusion. Resident #202 had increased agitation this afternoon and refused insulin and medications. Review of the MAR…

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 review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure an allegation of verbal abuse was reported to the state agency, in a timely manner. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 identified Resident #39 had Parkinson's disease and was at risk for complications and injury related to muscle rigidity, dysphagia, fatigue, tremor, and as the disease progresses, he/she may also be at risk for memory and speech changes. Interventions included assisting Resident #39 to meet ADL needs and to be patient and encourage…

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 review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure the abuse policy was followed regarding a staff member involved in an allegation of verbal abuse. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 identified Resident #39 had Parkinson's disease and was at risk for complications and injury related to muscle rigidity, dysphagia, fatigue, tremor, and as the disease progresses, he/she may also be at risk for memory and speech changes. Interventions included assisting Resident #39 to meet ADL needs and to be patient and…

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 review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure the quarterly MDS and quarterly social work assessment were comprehensively completed. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The social services assessment dated [DATE] was incomplete. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed. The care plan dated 1/16/24 identified Resident #39 was taking opioid medication to help manage moderate to severe chronic pain. Interventions included monitoring for and reporting adverse effects including seizures, anxiety, agitation, hallucinations, and depression to the physician. The care plan further identified Resident #39 was at risk for potential adverse effects due to psychotropic medication use.…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident # 20, #36) reviewed for comprehensive care planning, the facility failed to failed to develop and implement a comprehensive care plan. The findings include: 1. Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and diabetes type 2. The admission MDS assessement dated 2/3/24 identified Resident #20 had intact cognition, spinal stenosis- lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 had 2 care plans, one from dietary with a focus on obesity, not following diet at home with an intervention that included a controlled carbohydrate diet, and the second from the Activities Director with a focus on orientating to the facility with interventions that included one to one visits and calendar activities. An interview with the DNS on 2/27/24 at 10:00AM noted it is her expectation that comprehensive…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #18 and #302) reviewed for activities of daily living, the facility failed to ensure resident was provided the incontinent care timely and utilize briefs per standard of practice for (Resident #18) and the facility failed to ensure showers and personal hygeine needs were addressed for a newly admitted resident for (Resident #302). The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included dementia, urinary tract infections, right femur fracture and falls. admission assessment dated [DATE] at 7:25 PM identified there were no marks or open areas to the coccyx, buttocks, and peri areas. A physician's order dated 1/30/24 directed to give Lasix 20 mg every morning. The care plan dated 2/1/24 identified Resident #18 needs assistance for activities of daily living. Interventions included assisting as needed to meet toileting needs and incontinent care per…

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 3. Resident #18 was admitted to the facility on [DATE] with diagnoses which included fracture of the right femur, dementia, congestive heart failure, and chronic kidney disease. The admission MDS assessment dated [DATE] identified Resident #18 had severely impaired cognition, required maximal assistance with sitting to standing and lying to sitting on the side of the bed, sustained 1 fall with no injury since admission, had an active diagnosis of heart failure, and taking a diuretic. The care plan dated 2/20/24 identified Resident #18 was a fall risk due to multiple risk factors including impaired balance, pain, and unsteady gait. Interventions included the provision of a well-lit and clutter free environment, maintaining commonly used articles within easy reach, and ensuring the call bell remains in reach. The nurse's note dated 2/2/24 at 6:46 AM identified Resident #18 experienced an unwitnessed fall at approximately 6:00 AM, resident denied hitting his/her head and denied pain. Vital signs were obtained. Skin…

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 review of the clinical records, facility policies, and interviews for 2 of 3 residents (Resident #5) reviewed for pressure ulcers, the facility failed to complete weekly body audits and weekly Braden scales per the physician's order and failed to ensure a nurse assessment was documented upon identification of a new pressure wound and (Resident #8) the facility failed to complete weekly body audits, per the physician's order. The findings include: 1.a Resident #5 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, multiple sclerosis, and paraplegia. A Physician's order dated 7/3/23 directed to complete a body audit and Braden scale on shower days, every Monday, and document on the assessment tab. The quarterly MDS assessmet dated 11/22/23 identified Resident #5 had intact cognition, the presence of 1 stage 4 pressure ulcer, was always incontinent of bowel and bladder, and was dependent with toileting and bathing. The care plan dated 12/5/23…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #21) reviewed for respiratory care, the facility failed to follow physician's orders for routine cleaning and maintenance of the Cpap. The findings include: Resident #21 was admitted to the facility with diagnoses which included cancer, chronic pain, diabetes, and sleep apnea. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition was not completed and required no assistance with dressing and personal hygiene. Additionally, the MDS did not indicate Resident #21 utilized a Cpap. The November 2023 care plan did not identify the use of a Cpap. A physician's order dated 11/24/23 directed to apply Cpap at bedtime with a medium full-face mask at bedtime for sleep apnea, clean nasal and full-face mask with soap and water every morning, clean the non- disposable tubing with soap and water once daily on 7:00 AM-3:00 PM shift. Clean the headgear and masks every month on 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 20) reviewed for pain management, the facility failed to ensure a prescribed narcotic analgesic was available for administration. The findings include: Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and anxiety disorder. The admission MDS assessement dated2/3/24 identified Resident #20 had intact cognition, had spinal stenosis, lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 did not have a care plan for pain, pain management or opioid use. A physician's order dated 2/1/24 directed to administer Hydromorphone 4mg (opioid pain analgesic) for pain every 3 hours as needed, Clonazepam(Klonopin) 0.5mg daily for anxiety, Lidocaine Patch 4% applied daily to lower back for pain, Carisoprodol(Soma) 350mg daily for back spasms, Tylenol 1000mg twice daily for pain, Pregabalin(Lyrica)…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #21) reviewed for unnecessary medications, the facility failed to ensure the narcotic disposition record was accurate. The findings include: Resident #21 was admitted to the facility with diagnoses that included cancer, chronic pain, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #21 did not reflect cognition and pain. A physician's order dated 11/24/23 directed to apply 2 Fentanyl transdermal patch 100 mcg/hour and one Fentanyl 25 mcg/hour patch for a total of 225mcg/hour apply 3 patches transdermal every 72 hours for pain management and remove per schedule. A physician's order dated 1/17/2024 directed for removal and destruction of Fentanyl patches with 2 licensed staff. A review of the controlled substance disposition records for Fentanyl Transdermal patch dated 11/30/23 through February 2024 identified that two nurse's were not consistently signing off on…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 resident's(Resident #4 and Resident #21) reviewed for respiratory care, the facility failed to sanitize the glucometer after use and store nebulizer tubing and CPAP face mask in a sanitary manner. The findings include: 1. Resident # 4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease (COPD), with a readmission 2/23/24. The admission MDS assessment dated [DATE] identified Resident # 4 had intact cognition, required substantial assistance with sitting to lying in the bed, and toileting. The MDS also identified Resident #4 had anxiety disorder and depression. The care plan dated 2/14/24 identified a concern with diabetes, with interventions which included fingerstick as ordered by the physician and as needed. A physician's order dated 2/4/24 directed to check blood glucose level twice daily at 6:00AM and…

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 documentation and interviews, the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 7/2023 through 12/13/2023 (5 months and 2 weeks). The findings include: Interview with LPN #1 on 2/26/24 at 9:15 AM identified she has been employed by the facility since 12/13/23 as the Infection Preventionist (IP), staff development, and the wound nurse. LPN #1 indicated the DNS oversees her at this time. Interview with the DNS on 2/26/24 at 9:30 AM identified she has been in the DNS position for approximately 1 year. The DNS indicated she was aware of the facility not having a dedicated Infection Preventionist between 7/2023 until 12/13/23 (5 months and 2 weeks). The DNS indicated she had oversight of the the infection control program, the staff development, the wound program, supervisor at times, she worked on the floor as a nurse at times, and the DNS position until 12/13/23. The DNS indicated she had been overseeing the infection control program since LPN #6 had resigned…

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 review of the clinical record, observations, review of facility policy and interviews for one of two residents (Resident #1) reviewed for Activities of Daily Living (ADL), the facility failed to provide care per resident's preferences and in accordance with the plan of care. The findings include: Resident #1's diagnoses included Parkinson's disease, anxiety disorder, hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage and convulsions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was required extensive assistance of two-person physical support for personal hygiene and transfers. The care plan identified the resident requires assistance with all ADL and mobility. Resident uses the following assistive devices: wheelchair. Interventions included for current function status: to provide total assist of 1 person with daily bathing/grooming/mouth care, to transfer the resident with the assistance of two people via…

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 the clinical record, facility policy and interviews for one resident residents (Resident #11) reviewed for nutrition, the facility failed to assess the resident's nutritional status and failed to obtain a diet order from the physician upon admission and readmission from an acute care facility. The findings include: 1 a. Resident #11 was admitted [DATE] with diagnoses that included fracture of shaft of humerus, left arm, status post closed reduction. A Nutritional assessment dated [DATE] noted Resident #11 was admitted on [DATE] and placed on a regular diet, regular consistency with thin liquids. The nutritional care plan dated 7/16/21 and completed by the Registered Dietician (RD #1), identified Resident #11 required set assistance with meals. Interventions included: the provision of diet as ordered, to provide set-up assistance as needed and to encourage food/fluid intake. The admission MDS assessment dated [DATE], identified Resident # 11 was severely cognitively impaired, independent with…

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 the clinical record, review of facility documentation, review of facility policy and interviews reviewed for infection control, the facility failed to test unvaccinated staff in accordance with Centers for Disease Control and Prevention (CDC) recommendations. The findings include: Review of facility documentation of Staff Vaccination Roster on 9/30/21 at 11:30 A.M. identified 6 staff members with an unvaccinated status related to medical or religious exemptions. The 6 staff members identified are: NA #2, NA #3, NA #4, NA #5, TRD and COTA #1. Interview with DNS and RN #2 on 9/30/21 at 11:35 A.M. identified that the facility was performing testing twice a week on unvaccinated staff. In accordance with Centers for Disease Control and Prevention (CDC) Guidelines for Long Term Care Testing identified as of September 10, 2021 recommended an expanded screen testing of asymptomatic Healthcare Personnel (HCP) should be as follows: In nursing homes, unvaccinated HCP should continue to expanded screening testing based on the level of community transmission as follows: In…

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 review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #235) reviewed for fall, the facility failed to notify the physician of a change in condition for a resident who sustained a fall requiring transfer to an acute care facility for an evaluation and in accordance with facility policy. The findings include: Resident #235 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, systolic hypertension, sinus node dysfunction, pacemaker, and dementia. Resident Care Plan (RCP) dated 9/24/21 identified Resident #235 was alert and confused and required assist of two with mobility and transfers. The physician's orders dated 9/24/21 directed the placement of an indwelling Foley catheter. The nursing progress note dated 9/26/21 at 4:56 A.M. identified Resident #235 was found lying on the bedroom floor at 4:30 A.M. which resulted in the resident's Foley catheter partially dislodged and noted bleeding and trauma.…

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 review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #4) reviewed for falls, the facility failed to ensure fall quarterly assessments were conducted in accordance with facility policy and the plan of care to prevent future falls. The findings include: Resident #4 was admitted on [DATE] with diagnoses that included chronic kidney disease, adult failure to thrive and anemia. A Fall Risk assessment dated [DATE] identified a score of 4 indicating Resident #4 was not at risk for falling. The annual MDS assessment dated [DATE] identified Resident # 4 required supervised assist with bed mobility, transfers and locomotion in the room. The RCP dated 6/28/21 identified Resident #4 was at risk for falls. Interventions included: to have the call bell within reach when in bed or bedside chair, to encourage the resident to ask and wait for staff assistance for transfers and/or toileting, to reinforce need to use walker to ambulate independently in…

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 review of the clinical record, observations, review of facility policy and interviews for one out of thirty-three residents (Resident #1) reviewed for staffing, the facility failed to provide a sufficient number of personnel to meet the resident's needs. The findings include: Resident #1's diagnoses included Parkinson's disease, anxiety disorder, hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage and convulsions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was required extensive assistance of two-person physical support for personal hygiene and transfers. The care plan identified the resident requires assistance with all ADL and mobility. Resident uses the following assistive devices: wheelchair. Interventions included for current function status: to provide total assist of 1 person with daily bathing/grooming/mouth care, to transfer the resident with the assistance of two people via Hoyer lift and 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.