Apple Rehab Colchester

Based on facility documentation review, facility policy review and interviews for facility QAPI review, the facility failed to ensure the facility was able to maintain compliance with deficiencies previously identified. The findings include: A complaint survey was completed on 2/22/2024 with findings related to abuse and reporting allegations of abuse to the State Agency timely. The Facility plan of correction (POC) identified audits would be conducted for 30 days or until substantial compliance with QAPI oversight. Facility documentation review identified nine (9) grievances (Residents #1, 4, 9, 10, 11, 12, 13, 14 and 15) regarding allegations of lack of care and/or allegations of abuse/mistreatment that were not reported to the State Agency timely and lacked documentation of comprehensive investigations. Review of the 4/22 and 7/11/2024 QAPI meetings failed to identify the meetings included a review of allegations of abuse/mistreatment and/or grievances. Additional review failed to identify the QAPI directed to discontinue the audits. Review of facility documentation 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 clinical record review, facility documentation review, facility policy review, and interviews for eight of nine residents (Resident #13, #14, 15, 12, 11, 1, 10 and 9) reviewed for grievances, the facility failed to ensure grievances were responded to timely and failed to ensure the complainant was notified of the results timely. The findings include: 1. Resident #13's diagnoses included convulsions (rapid, involuntary muscle contractions and relaxations resulting in uncontrolled shaking and limb movement), weakness, and anxiety. The admission MDS assessment dated [DATE] identified Resident #13 had moderate cognitive impairment, exhibited no behaviors and required moderate assistance with ADLs and toileting. The Resident Care Plan dated 7/30/2023 identified Resident #13 required staff assistance with ADLs. Interventions directed to assist as needed to meet toileting needs, and incontinent care per policy. Review of the Concern Form dated 7/30/2023 alleged Resident #13 required incontinent care, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two (2) of eighteen (18) residents, (Resident #9 and 10), reviewed for abuse, the facility failed to ensure a comprehensive care plan was developed timely to include resident refusals of care. The findings include: 1. Resident #9's diagnoses included Alzheimer's disease, encephalopathy (disturbance of brain function), polyneuropathy (damage of multiple peripheral nerves), unstageable pressure ulcer of back and failure to thrive. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was had moderate cognitive impairment, exhibited no behaviors and required moderate assistance with bed mobility and transfers and maximal assistance with toileting. The Resident Care Plan dated 7/3/2024 identified that Resident #9 required staff assistance with Activities of Daily Living (ADL's) with interventions that directed to assist as needed to meet toileting needs, incontinent care per policy,…

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 two (2) of eighteen (18) residents, (Resident #1 and #7), reviewed for abuse, the facility failed to ensure Resident Care Conferences were held with the resident and/or resident representative quarterly in accordance with facility policy. The findings include: 1. Resident #1's diagnoses included multiple myeloma (cancer of white blood cells in the bone marrow), type II diabetes mellitus, anemia and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors, required moderate assistance for transfers and toileting, and Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) identified that Resident #1 required staff assistance with Activities of Daily Living (ADL's) and toileting with interventions that directed to assist with toileting needs. Prior to the 3/3/2024 MDS, the ADL RCP…

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 (1) of eighteen (18) residents, (Resident #22), reviewed for abuse, the facility failed to ensure monitoring was provided in accordance with the plan of care and/or in accordance with physician orders. The findings include: Resident #22's diagnoses included Alzheimer's disease, epilepsy (seizure disorder), dementia with psychotic disturbances and an adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had moderate cognitive impairment, exhibited no behaviors and required supervision assistance with bed mobility, transfers, personal hygiene and toileting. The Resident Care Plan dated 1/26/2024 identified Resident #22 had a history of being impulsive and was not consistently able to control his/her behavior. Interventions directed to offer clear and simple explanations of tasks and occurrences, avoid information overload when he/she is angry or…

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 sampled resident (Resident #4) reviewed for care and services, the facility failed to ensure adequate staffing to ensure resident care was provided timely to include transfer out of bed before lunch in accordance with resident wishes. The findings include: Resident #4 's diagnoses included myoneural disorder (weakened muscles due to improper nerve and muscle signal transmission), spinal stenosis (narrowing of the space around the spinal cord putting pressure on the spinal cord and nerves, causing pain), functional quadriplegia, contractures of the right hand, left hand and right elbow, and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was severely cognitively impaired, exhibited no behaviors and was dependent on staff for bed mobility, and transfers. The Resident Care Plan dated 5/2/2024 identified that Resident #4 required assistance with all Activities…

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 for two (2) of five (5) nurse's aides reviewed for performance evaluations, the facility failed to ensure nurse's aides received annual performance evaluations. The findings included: 1) NA #6 had a hire date of 9/26/2022 and was due to have his/her annual performance review in 2023, however documentation of his/her performance review was not available for review in his/her personnel file and could not be located. 2) NA #8 had a hire dare of 10/6/2022 was due to have his/her annual performance review on 2023, however documentation of his/her performance review was not available for review in his/her personnel file and could not be located. Interview with the Director of Clinical Services (DCS) on 8/5/2024 at 2:50 PM identified the NA performance evaluations were to be completed annually by the Director of Nurses. The DCS further indicated performance evaluation documentation should have been completed for both NA #6 and NA #8 for their annual performance review, but the facility was unable to locate their performance…

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 seven (6) of twenty-three (23) residents, (Resident #1, 10, 11, 12, 13, and 14), reviewed for abuse, the facility failed to ensure the residents were provided social services support timely after an allegation of mistreatment. The findings include: 1. Resident #1's diagnoses included multiple myeloma (cancer of white blood cells in the bone marrow), type II diabetes mellitus, anemia, and chronic kidney disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required moderate assistance for bed mobility, transfers and toileting and was frequently incontinent of both bowel and bladder. The Resident Care Plan dated 3/13/2024 identified that Resident #1 required staff assistance with Activities of Daily Living (ADLs) with interventions that directed to assist as needed with toileting needs. a. Review of the Concern Form dated…

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 two of eighteen residents (Resident #4 and #21) reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include documentation of meal intakes and weekly showers. The findings include: 1. Resident #4's diagnoses included spinal stenosis (narrowing of the space around the spinal cord) and dysphagia. The quarterly MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment and was dependent on staff for ADLs and maximum assist for ADLs and eating. The Resident Care Plan dated 5/2/2024 identified Resident #4 required assistance with all ADLs, had contractures and utilizes a customized motorized wheelchair. Interventions directed assist with ADLs. Physician order dated 4/17/2024 directed to assist Resident #4 for feeding. Interview with Recreation Aide (RA) #2 on 8/1/2024 at 1:02 PM identified on 7/31/2024 at 1:30 PM when she entered the (front)…

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, facility documentation, facility policies and interviews for three of nine sampled residents (Residents #2, #3, and #7) who had an alteration in skin integrity, the facility failed to change the wound dressings in accordance with the physician's order. The findings include: 1. Resident #2's diagnoses included dementia, contractures of the lower leg, right hand, right elbow, and left hand, neuromuscular dysfunction of the bladder, neurogenic bowel, and dermatitis to the buttocks. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had some short- and long-term memory deficits, was dependent on staff for activities of daily living, had an indwelling urinary catheter, was always incontinent of bowel, and had no skin breakdown. The Resident Care Plan (RCP) dated 1/19/24 identified Resident #2 required assistance with activities of daily living, was incontinent of bowel, was at risk of skin breakdown, and had moisture associated skin damage (MASD).…

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, facility documentation, facility policies and interviews for four of nine sampled residents (Residents #1, #4, #5, and #6) who had a pressure ulcer, the facility failed to change the wound dressings in accordance with the physician's order. The findings include: 1. Resident #1's diagnoses included Stage Four (4) pressure ulcer to the right hand, dementia, and contractures of the right and left hands. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living and had no skin injuries. The Resident Care Plan (RCP) dated 4/6/24 identified Resident #1 was at risk for changes in skin integrity. Interventions directed weekly skin checks, hand splints, occupational therapy services as ordered, pressure reducing air mattress, wound care consults as needed, and wound care treatments per physician's order. The physician's progress note dated 4/8/24 at 9:41 AM identified the right 4th digit wound was…

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, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who had sustained a laceration, the facility failed to develop routine preventive maintenance of bed rails to protect a resident from an injury that resulted from an uncapped side rail. The findings include: Resident #1's diagnoses included dementia, repeated falls, difficulty walking, lymphedema, and peripheral vascular disease with long term use of anticoagulants. The Resident Care Plan dated 12/23/23 identified Resident #1 had peripheral vascular disease and required assistance with activities of daily living. Interventions directed to administer medications as ordered, side rails and assistive devices to promote safety and independence, transfers in and out of the bed and chair per physician's order, maintain the call bell in reach, use of proper footwear, offer toileting every hour, and maintain a well-lit, clutter free environment. The quarterly 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to ensure a change in condition was reported timely to the physician and the responsible party. The findings include: Please cross reference F 600 1. Resident # 1 had diagnoses that include Alzheimer's disease, epilepsy, and essential hypertension. The care plan dated 1/5/2024 identified Resident #1 can be impulsive and not always able to control behavior with interventions that directed if Resident #1's mood is changing, becoming angry offer to assist to another area, spend a few minutes in quiet conversation until any anger subsides. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and supervision with use of a rolling walker…

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 (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to ensure residents were free from abuse. The findings include: 1. Resident # 1 had diagnoses that include Alzheimer's disease, epilepsy, and essential hypertension. The care plan dated 1/5/2024 identified Resident #1 can be impulsive and not always able to control behavior with interventions that directed if Resident #1's mood is changing, becoming angry offer to assist to another area, spend a few minutes in quiet conversation until any anger subsides. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and supervision with use of a rolling walker with ambulation. 2. Resident #2 had diagnoses that include Alzheimer's disease,…

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 three (3) of three (3) residents (Resident #1, Resident #2 and Resident #3) reviewed for abuse, the facility failed to report two residents to resident sexual incidents to the state agency within the required time frame. The findings include: Please cross reference F 600 1. Resident # 1 was admitted to the facility with diagnoses that include Alzheimer's disease, epilepsy, and essential hypertension. The care plan dated 1/5/2024 identified Resident #1 can be impulsive and not always able to control behavior with interventions that directed if Resident #1's mood is changing, becoming angry offer to assist me to another area, spend a few minutes in quiet conversation with me until my anger subsides. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required assistance with bed mobility, transfers,…

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 (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure a comprehensive care plan with appropriate interventions was implemented for a resident with wandering behaviors. The findings include: Resident #1 had diagnoses that include Alzheimer's disease, epilepsy, and essential hypertension. The nursing admission assessment dated [DATE] identified Resident #1 had wandering behavior. The care plan dated 1/5/2024 identified Resident #1 can be impulsive and not always able to control behavior with interventions that directed if Resident #1's mood is changing, becoming angry offer to assist to another area, spend a few minutes in quiet conversation until any anger subsides. The nurse's note dated 1/7/2024 at 4:26 A.M. LPN #2 identified Resident #1 was confused, wandering in the hallway and his/her room. The nurse's note dated 1/7/2024 at 11:27 P.M. LPN #2 identified Resident #1 was…

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, review of facility policy, and interviews for one of nineteen residents (Resident #356) reviewed for advance directives, the facility failed to ensure there was a physician's order indicating the resident's wishes related to cardiopulmonary code status, hospitalization, and intravenous fluids. The findings include: Resident #356's diagnoses included displaced right humerus fracture, heart failure, and mitral valve disease. The Nursing admission assessment dated [DATE] identified Resident #356 was cognitively intact, required the assistance of one person with transfers and positioning, and was non-weight bearing to the right upper extremity. The Resident Care Plan dated [DATE] identified Resident #356 required assistance with activities of daily living with an intervention to provide advance directives per the physician orders. Review of the clinical record identified a Medical Interventions Consent form that was signed by the resident's representative, as well as LPN #2 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 observations, clinical record review, review of facility's documentation and interviews for one sampled resident (Resident #28) who required extensive assistance with personal care, the facility failed to ensure that the resident was free of facial hair. The findings include: Resident #28's diagnoses included severe protein malnutrition, dementia, Parkinson's disease, orthostatic hypotension, iron deficiency anemia, syncope and collapse, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #28 was cognitively intact with no mood or behavioral issues, required supervision with eating, and extensive assistance with personal hygiene and all other activities of daily living, was non-ambulatory and utilized a wheelchair for mobility. Intermittent observations on 05/08/2023, 05/09/23, 05/11/2023 and 05/16/2023 identified Resident #28 involved in activities in the dining room with visible long, white facial hair noted below the lower lip. Interview with Resident #28 on 05/08/2023…

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 clinical record reviews, review of facility documentation and interviews for one of six sampled residents (Resident #28) receiving an antipsychotic medication and one of four sampled residents (Resident #46) reviewed for pressure ulcers, the facility failed to ensure physician's orders were followed regarding the monitoring of orthostatic blood pressures and failed to ensure that the dietician was notified timely after a new pressure ulcer wound was identified. The findings include: 1. Resident #28's diagnoses included severe protein malnutrition, orthostatic hypotension, iron deficiency anemia, syncope and collapse, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had no cognitive impairment mood or behavioral issues, required supervision with eating, and extensive assistance with other activities of daily living. MDS also identified that Resident #28 received antipsychotic, antidepressant, and antianxiety medications. A review of the Resident…

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, clinical record review, facility policy review, and interviews for one sampled resident (Resident #27) reviewed for limited range of motion, the facility failed to ensure splints were applied per the physician's orders. The findings include: Resident # 27's diagnoses included functional quadriplegia, right elbow contracture, left hand contracture, cerebral vascular accident, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #27 had severe cognitive impairment, required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. The assessment further identified the resident required total assistance with transfers, was non-ambulatory, had functional limitations in range of motion to bilateral upper extremities and bilateral lower extremities and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 3/9/23 identified Resident #27 was at risk for contractures of the right elbow and the left hand due to cerebral vascular…

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, review of facility documentation, review of facility policy and interviews for one of two sampled residents (Resident #356) who acquired assistance with transfers and was reviewed for accidents, the facility failed to ensure the utilization of a gait belt during a transfer. The findings include: Resident #356's diagnoses included displaced right humerus fracture, heart failure, and mitral valve disease. The Nursing admission assessment dated [DATE] identified Resident #356 was cognitively intact and required the assistance of one person with transfers, and positioning. The assessment further identified the resident was non-weight bearing to the right upper extremity. The Resident Care Plan dated 4/30/23 identified that Resident #356 required assistance with activities of daily living with an intervention for one-person physical assistance with transfers. Review of the Reportable Event report and investigation dated 5/8/23 identified Resident #356 alleged that on 5/7/23 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 clinical record review, review of facility policy, and interviews, for one of four sampled residents (Resident #24) reviewed for nutrition, the facility failed to ensure a dietician's recommendation was followed. The findings include: Resident #24's diagnoses included Diabetes Mellitus, Hypertension, Myocardial Infarction (Heart Attack). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #24 was cognitively intact, requiring extensive assistance of two staff for mechanical lift transfers and, after set up, was able to eat with supervision. Review of the care plan dated 3/22/23 identified a significant weight gain. Resident #24 was at risk for proper nutrient utilization related to Diabetes Mellitus. Interventions directed to provide diet as ordered, offer preferred foods, refer to Registered Dietician evaluation and recommendations as needed. Review of the clinical record identified that the Dietician had made a recommendation to discontinue the fortified mashed potatoes 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 clinical record review, review of facility policy, and interviews, for one of four sampled residents (Resident #24) reviewed for nutrition, the facility failed to ensure a dietician's recommendation was followed. The findings include: Resident #24's diagnoses included Diabetes Mellitus, Hypertension, Myocardial Infarction (Heart Attack). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #24 was cognitively intact, requiring extensive assistance of two staff for mechanical lift transfers and, after set up, was able to eat with supervision. Review of the care plan dated 3/22/23 identified a significant weight gain. Resident #24 was at risk for proper nutrient utilization related to Diabetes Mellitus. Interventions directed to provide diet as ordered, offer preferred foods, refer to Registered Dietician evaluation and recommendations as needed. Review of the clinical record identified that the Dietician had made a recommendation to discontinue the fortified mashed potatoes 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 clinical record review, observations, review of facility documentation, facility policy review, and interviews for one sampled resident (Resident #10) who was reviewed for the use of a physical restraint, the facility failed to utilize a lap tray on the wheelchair in accordance with the physician's order to ensure the resident's movement was not restricted and failed to conduct restraint evaluations to determine if the lap tray was utilized as a restraint. The findings include: Resident #10's diagnoses included Alzheimer's disease, non-Alzheimer's dementia with behavioral disturbances, ataxic gait, and dysphasia (difficulty or discomfort with swallowing). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 rarely or never made decisions regarding tasks of daily life, and exhibited both physical and verbal behavioral symptoms, such as hitting, kicking, scratching, grabbing, verbal threats or screaming at others. The assessment identified Resident #10 required extensive one (1)…

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, review of facility documentation and interviews for one sampled resident (Resident #15) who was reviewed for non-pressure skin conditions, the facility failed to monitor and ensure the manufacturer's guidelines related to a heat therapy treatment device were followed to prevent the resident from sustaining a burn. The findings include: Resident #15's diagnoses included spinal stenosis, and contractures of the left hip and left knee. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #15 had no cognitive impairment, required extensive assistance of two (2) staff with bed mobility, and had functional limitation in the range of motion to the lower extremities (hip, knee, ankle, foot) on both sides. The Resident Care Plan dated 6/21/20 identified Resident #15 was at risk for skin breakdown. Interventions directed to inspect skin when giving care for signs and symptoms of breakdown. A physician's physical therapy order dated 8/13/20 directed electrical…

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 and interviews for one of three residents (Resident #14) who were reviewed for allegation of mistreatment, the facility failed to ensure psychosocial support was provided to the resident after the incident. The findings include: Resident #14's diagnoses included Alzheimer's disease, major depressive disorder and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, supervision with walking in room, corridor, and locomotion on the unit. The Resident Care Plan dated 6/17/20 identified Resident #14 was at risk for an alteration in mood, behaviors due to psychiatric and cognition diagnosis, confusion, weepiness and restlessness at time. Interventions directed to be aware of changes in Resident #14's mood and behavior. The Reportable Event Form dated 7/25/20 identified Resident #14 reported to a nurse aide that Resident #11…

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 review, review of facility documentation, review of facility policy, and interviews for one of five residents reviewed for unnecessary medications residents (Resident #20), the facility failed to discontinue a medication as needed on the medication adminstration record and the monthly physican's order sheets after the phsyician had discontinued the medication. The findings include: Resident #20's diagnoses included diverticulitis, history of abdominal pain, and vascular dementia. A physician's order dated 9/1/20 directed to give Dicyclomine (Bentyl) 20 milligrams (mg) tablet one (1) tablet four (4) times daily as needed for abdominal cramping. A physician's order dated 9/24/20 directed to discontinue the Dicyclomine (Bentyl) 20mg tablet four times daily as needed. Review of the September 2020 Medication Administration Record (MAR) identified the Dicyclomine was discontinued on 9/24/20. Review of the physician's orders and Medication Administration Records for October, November and December of 2020 identified that the Dicyclomine (Bentyl) 20 mg tablet order…

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, review of facility documentation and interviews for one of five sampled residents (Resident #18) reviewed for unnecessary psychotropic medication use, the facility failed to monitor orthostatic blood pressures in accordance with the physician's order and facility policy, and the facility failed to monitor targeted behaviors specific to antipsychotic medication use. The findings include: Resident #18's diagnoses included dementia with behavioral disorder, Alzheimer's disease, and major neurocognitive disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #18 rarely or never made decisions regarding tasks of daily living, no mood issues, no behaviors or rejection of care, and ambulated and transferred independently. The resident care plan dated 9/15/20 identified a potential for adverse effects secondary psychotropic drug use. Interventions included to monitor for medication side effects and conduct orthostatic blood pressures per facility policy. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility documentation, review of facility policy, and interviews for three of seven sampled residents (Resident #8, #29 and #38) observed during medication administration, the facility failed to ensure that residents wore identification band or the charge nurse verified the resident's identify by another form of visible identified to prevent a medication error. The findings include: Resident #38's diagnoses included Alzheimer's disease and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #38 was not able to make decisions regarding tasks of daily life. A physician's order dated 11/29/20 directed to give Trazadone 25mg by mouth daily at 12:00PM and Artificial Tears 1.4% 1 drop in both eyes four (4) times a day and to check the resident's identification band prior to medication administration. Resident #8's diagnoses included bipolar disorder and adjustment disorder. The quarterly Minimum Data Set assessment dated [DATE]…

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 observation and interviews for one of two medication rooms and two of three medication carts, the facility failed to ensure medications were secured in a locked medication storage area. The findings include: 1. Observations on the secured dementia unit on 12/16/20 at 6:40 AM identified the Medication Storage Room door was propped completely open using an oxygen cylinder tank and a medication cart inside the room was unlocked and there was a water basin with six (6) blister packs of medication on the back counter. In the hallway near the nurse's station Resident #22 was ambulating independently. An interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #3 on 12/16/20 at 6:45 AM identified at times she leaves the medication storage room propped open. LPN #3 indicated she had gone down the hall to bring the hoyer lift to a nurse aide. An interview with the former Director of Nursing, (DON) #1, on 12/16/20 at 6:46 AM identified LPN #3 should always have the medication room door closed and locked and the medication carts should be locked if the nurse was not…

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, observations, review of facility documentation, facility policy review, and interviews for one sampled resident (Resident #10) who was reviewed for the utilization of adaptive equipment during meals, the facility failed to provide the resident with a special beverage cup to maintain promote, or improve their ability to eat or drink independently. The findings include: Resident #10's diagnoses included Alzheimer's disease, non-Alzheimer's dementia with behavioral disturbances, ataxic gait, and dysphasia (difficulty or discomfort with swallowing). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #10 rarely or never made decisions regarding tasks of daily life and required extensive one (1) person assistance with eating. The resident care plan dated 9/12/20 identified altered nutrition, impaired hydration, inadequate intake related to impaired cognition. Interventions directed to provide set up of meals, provide prompting, cueing as needed, and feed during…

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 documentation, facility policy review, and interviews, the facility failed to implement infection control techniques to prevent the possible transmission of COVID-19. The findings include: An interview with the former Director of Nursing (DON) #1, on 12/14/ 20 at 10:00 AM identified all residents on the secured dementia unit were on Droplet/Contact precautions due to COVID-19 exposure. DON #1 indicated that all staff were required to wear a face shield, surgical mask, isolation gown and gloves when entering resident rooms, and to remove when exiting resident rooms. 1. Observations on the secured dementia unit on 12/14/20 at 11:50 AM identified a nurse aide, Nurse Aide (NA) #7, stood near the resident rooms with a box of surgical masks while NA #3 was observed to enter resident room and apply a surgical mask on the resident. NA #3 was observed to enter the rooms of Resident #19, Resident #25, Resident #4, Resident #9 and R #6 without wearing an isolation gown or gloves. NA #3 was observed to apply a face mask to each resident, touching each…

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.