Apple Rehab Cromwell

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, and facility policy for 1 of 4 sampled residents (Resident #5) reviewed for accidents, the facility failed to obtain and document orthostatic (positional) blood pressures per the physician's order, failed to ensure the resident's condition was documented for 72 hours following a fall per the facility practice, and for 1 of 3 sampled residents (Resident #44) reviewed for pressure ulcers, the facility failed to set an alternating pressure mattress at the correct setting, per the physician order and Resident Care Plan. The findings include. The findings include: 1.Resident #5's diagnosis included fracture of the neck of the femur with subsequent encounter for closed fracture with routine healing (hip fracture). The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and had no history of falls. The Resident Care Plan dated 6/17/25 indicated Resident #5 was at risk for falls due to psychotropic…

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, interviews, and facility policy for 2 of 3 sampled residents (Resident #12 and Resident #38) reviewed for Intravenous (IV) therapy, the facility failed to ensure staff obtained physician orders for routine care and maintenance of peripherally inserted IV sites and failed to consistently document observations of the IV site and the presence or absence of adverse reactions per the facility policy. The findings include. 1. Resident #12's diagnosis included chronic renal disease and urinary tract infection.The quarterly Minimum Data Set (MDS) dated [DATE] indicted Resident #12 had moderate cognitive impairment.A physician order dated 11/13/25 directed to provide Dextrose-Sodium chloride Intravenous Solution 5-0.45% 75 milliliters per hour (ml/hr.) every shift for fever/hydration for 3 days for a total of 3 liters.The Resident Care Plan dated 11/14/25 indicated Resident #12 was receiving IV hydration via a peripherally inserted catheter in the left upper extremity due to fever,…

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 interviews, and record and policy reviews for the only sampled resident (Resident # 7) reviewed for pain, the facility failed to review the clinical record to ensure appropriate management of pain. The findings include:Resident #7's diagnoses included displaced fracture of the right femur, polyneuropathy, and anxiety.The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, was independent with eating, required partial/moderate assistance with dressing and toileting hygiene, and received scheduled and as needed pain medications. The Pain Assessment interview identified Resident #7 had pain or was hurting frequently in the 5 days prior to the assessment, the pain frequently made it hard to sleep at night, and he/she frequently limited day to day activities due to pain.The Resident Care Plan dated 10/25/25 identified Resident #7 was at risk for pain/discomfort related to a hip fracture.…

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 interviews, review of the clinical record and facility policy, for 2 of 5 sampled residents (Resident #5 and Resident #54) reviewed for unnecessary medications, for Resident #5 the facility failed to ensure a Monthly Medication Regimen review was completed, and for Resident #54, the facility failed to ensure a timely response to a pharmacist recommendation. The findings include:1.Resident #5's diagnosis included Parkinson's disease, schizoaffective disorder, bipolar disorder, anxiety disorder and epilepsy. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #5 had mild cognitive impairment and was receiving antipsychotic, antidepressant, anticoagulant and anticonvulsant medications. The Resident Care Plan dated 9/30/25 identified Resident #5 was at risk for seizures, changes in mood and behavior, and at risk for potential adverse effects from the use of psychotropic medications and anticoagulation therapy. Interventions included evaluating the effectiveness, side effects, and results of…

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, facility policy, and interviews during a review of medication storage and labeling, for 1 of 2 medication rooms observed, the facility failed to ensure that expired medications were discarded, failed to ensure medications were labeled appropriately, and failed to ensure medications requiring refrigeration for 5 residents (Resident #3, 10, 14, 39 and 55) were stored at the appropriate temperature. The findings include:1.Observation of the North Wing medication storage room on 12/3/25 at 11:58 AM identified the following: One bottle of Gastrografin incorrectly labeled (the bottle had a partial name tag; however, the residents name was torn off). One Normal saline flush with an expiration date of 8/13/24. Four Heparin Lock Flushes, 50 unit/5ml expired on 3/31/24. One IV Start kit and one IV clamp that expired 4/3/23. Ice buildup was noted in the refrigerator. A temperature log dated 12/1/25 identified a medication refrigerator temperature of 22.1 degrees F (normal to 46 degrees Fahrenheit (F). A temperature log dated 12/2/25 identified a medication refrigerator…

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, interviews, review of the clinical record and facility policy for the only sampled resident, (Resident #6), reviewed for dental services, the facility failed to assist with obtaining routine dental services upon request. The findings include:Resident #6's diagnoses included Turner's syndrome, type 2 diabetes, and gastroparesis.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required touching assistance with chair/bed-to-chair transfers, required set-up assistance with oral hygiene, and had a problem with vomiting.The Resident Care Plan (RCP) in effect from 9/22/25 through 12/3/25 identified Resident #6 had gastroparesis but failed to include an oral intervention for vomiting due to gastroparesis, failed to include the risk for tooth erosion from stomach acids, and failed to identify that Resident #6 was at risk for various dental issues related to his/her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, facility documentation and policy review, the facility failed to develop, monitor and implement an effective Quality Assurance Performance Improvement plan. The findings include:Review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes dated 1/22/25, 4/23/25, and 7/23/25 identified quality measures were reviewed without the benefit of any identified plan, education, or audits to ensure compliance. Additional review of QAPI documentation failed to identify an annual performance improvement plan.Interview and review of the facility QAPI/Performance improvement information with the Director of Nursing (DNS) on 12/4/25 at 11:35 AM identified she was in charge of Quality Assurance and Performance Improvement program in the facility. She stated that the policy directed the facility to identify areas of concern and take actions to improve those areas. Review of the quarterly meetings with the DNS identified that formal meetings were held quarterly, but the only quarter that included a QAPI was dated 10/29/25 and was based on a family suggestion…

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, interviews, and facility policy for Resident #22 and Resident #65, the facility failed to follow infection control practices on 1 of 3 units to provide a clean environment, by improperly storing disposable medical equipment. During a tour of the laundry area, the facility failed to ensure a clean environment for laundry and for 1 of 4 residents reviewed for pressure ulcers, the facility failed to use appropriate hand hygiene and personal protective equipment (PPE) when providing wound care. The findings include: 1. Resident #22's diagnoses included a right femur fracture, history of falling, and muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #22 was cognitively intact and required moderate assistance with bed mobility and was dependent with transfers and toileting. 2. Resident #65's diagnoses included a right tibia fracture, history of falls, and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65…

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 1 of 4 residents (Resident #39) reviewed for accidents, the facility failed to ensure a dignified dining experience. The findings include: Resident #39's diagnoses included vascular dementia, history of stroke, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #39 had severely impaired cognition, was always incontinent of bowel and bladder and required a mechanically altered diet with set up with meals. The Resident Care Plan dated 2/26/24 identified Resident #39 was at risk for aspiration due to difficulty swallowing. Interventions included to provide 1 to 1 supervision with eating and to follow up with speech pathology (SLP) for safe swallowing techniques. The physician's order dated 5/23/24 identified Resident #39 directed a dysphagia advanced Level 3 texture diet order in place with supervision at mealtime to include cueing for small bites and slow rate. Further review of…

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 policy, and interviews for 3 of 24 residents (Resident #69, Resident #474, and Resident #572) reviewed for Advance Directives, the facility failed to obtain Advance Directives upon admission and failed to ensure the resident's preference was honored according to the physician order. The findings include: 1. Resident #69's diagnoses included emphysema, chronic obstructive pulmonary disease, and urinary tract infection. Review of the written Advance Directive Form dated [DATE] and signed by Resident #69 and LPN #3 directed a Do Not Resuscitate (DNR) status. The form lacked the physician's signature. A physician's order dated [DATE] directed facility staff to perform Cardiopulmonary Resuscitation (CPR) in the event of a change in status (a discrepancy with the written Advance Directive Form which indicated DNR). The Resident Care Plan dated [DATE] indicated Advanced directives per resident/representative and per the physician orders. A Nurse Practitioner Note 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 staff interviews, record review, review of facility documentation and facility policy for 1 of 2 sampled residents (Resident #13) reviewed for mistreatment, the facility failed to ensure Resident #13 was not treated in a scolding manner. The findings include: Resident #13's diagnoses include adjustment disorder with mixed anxiety and depressed mood, unspecified dementia and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired and required extensive assistance of 2 persons with transfers and toileting. The Resident Care Plan (RCP) dated 2/1/24 identified Resident #13 had a problem with determining what was real and what was not, which had proven to hinder some of his/her interactions with peers. Interventions included offering gentle reminders of reality awareness regarding time, place and surroundings. On 4/1/24 at 3:00 PM during the Resident Council meeting, Resident #13 identified that he/she had reported an incident…

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 staff interviews, record review, review of facility documentation and facility policy for 1 of 2 sampled residents (Resident #13) reviewed for mistreatment, the facility failed to prevent a Nurse Aide (NA #3) from working during an investigation of mistreatment. The findings include: Resident #13's diagnoses include adjustment disorder with mixed anxiety and depressed mood, unspecified dementia and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was moderately cognitively impaired and required extensive assistance of 2 persons with transfers and toileting. The Resident Care Plan (RCP) dated 2/1/24 identified Resident #13 had a problem with determining what was real and what was not, which had proven to hinder some of his/her interactions with peers. Interventions included offering gentle reminders of reality awareness regarding time, place and surroundings. On 4/1/24 at 3:00 PM during the Resident Council meeting, Resident #13 identified that he/she…

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 4 residents (Resident #13 and Resident #40) reviewed for timeliness of providing Activities of Daily Living (ADLs), the facility failed to report an allegation of mistreatment to the State Agency. The findings include: 1. Resident #13's diagnoses include adjustment disorder with mixed anxiety and depressed mood, unspecified dementia and anxiety disorder. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #13 was moderately cognitively impaired and required extensive assistance of 1 with transfers and toileting. The Resident Care Plan (RCP) dated 2/1/24 identified Resident #13 had a problem with determining what was real and what was not, which had proven to hinder some of his/her interactions with peers. Interventions included offering gentle reminders of reality awareness regarding time, place and surroundings. On 4/1/24 at 3:00 PM during the Resident Council meeting, Resident #13 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 observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 sampled residents (Resident #30, Resident #65) reviewed for skin conditions, the facility failed to properly transcribe physician orders resulting in physician orders not being followed (Resident #30) and failed to follow physician's orders regarding Braden Scale Assessments and weekly body audits (Resident #65). Additionally, for the only sampled resident (Resident #71) reviewed for death, the facility failed to ensure that vital signs were taken per the physician orders. The findings include: 1. Resident #30 was admitted to the facility on [DATE] with diagnoses that included cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus (MRSA), acute kidney failure, and edema. A Nursing admission note dated 3/7/24 at 8:03 PM and written by RN #4 identified Resident #30 was alert, aware with confusion, had eschar open areas to bilateral lower extremities (BLE), with a treatment of…

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 2 of 3 sampled residents (Resident #31 and Resident #53) who had a pressure ulcer/injury, the facility failed to ensure Braden scales and body audits were completed per the facility's policy and the physician's orders (Resident #31), and failed to ensure a low air loss mattress was set at the appropriate setting for Resident #53's weight. The findings include: 1. Resident #31's was admitted on [DATE] with diagnoses including femur fracture (left thigh bone), peripheral vascular disease (poor circulation in lower extremities), and heart failure. The Nursing admission assessment dated [DATE] identified Resident #31 was alert and confused and required 1-2 people for assistance with bed mobility and transfers. Additionally Resident #31's skin was noted to be intact and a Braden scale identified that Resident #31 was at mild risk to develop a pressure ulcer. The admission physician's order dated 3/2/24 directed a licensed nurse 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #53) reviewed for nutrition, the facility failed to ensure that a monthly weight and reweight was obtained after a significant weight loss. The findings include: Resident #53's diagnoses included cerebral vascular accident, dementia, and mitral valve insufficiency. Review of the Weights and Vitals Summary identified Resident #53 was weighed on 9/15/23 with a weight of 174.9 pounds and not reweighed again until 1/4/24 with a weight of 176.5 pounds. Resident #53 was not weighed in February 2024. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #53 was moderately cognitively impaired, required a mechanical lift, and was totally dependent with assist of 2 for transfers and toileting. Additionally, the MDS identified Resident #53 was extensive assist of 2 for bed mobility and was independent with set up for eating. Review of the Weights and Vitals…

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 of 1 sampled resident (Resident #61) reviewed for respiratory therapy, the facility failed to administer oxygen at the correct setting, per physician orders. The findings include: Resident #61's diagnoses included acute respiratory failure with hypoxia, Covid-19, and hypertension. A physician's order dated 1/11/24 directed oxygen at 2 liters (L) continuously, to maintain oxygen saturation greater than 90% every shift, for shortness of breath. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 was moderately cognitively impaired, was a total mechanical lift with assist of 2, extensive assistance of 1 with eating, extensive assist of 2 for bed mobility, and was dependent with assist of 2 for toileting. Also, the MDS identified that Resident #61 utilized oxygen. Observation on 3/27/24 at 12:23 PM and on 3/28/24 at 9:30 AM identified Resident #61 had a nasal cannula 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.

Based on observations, interviews and review of the facility policy related to medication storage, the facility failed to properly secure a controlled substance and properly secure a medication storage room. The findings include: a. Interview and observation of the East medication storage room with LPN #2 on 4/2/24 at 2:30 PM identified that the controlled drug box inside of the refrigerator was unlocked and found to contain one 30 milliliter (ml) unopened bottle of Lorazepam (a schedule 4 controlled substance) 2 milligram (mg)/ml inside. An additional padlock was observed outside of the refrigerator door which was also found to be unlocked/not engaged. LPN #2 stated she was aware that the controlled drug box inside of the refrigerator had a broken lock and could not be secured. LPN #2 further identified that she had notified the Maintenance Department and the DNS but that it had not been repaired or replaced yet. Additionally, LPN #2 stated she was aware the lock outside of the refrigerator should have been secured and that she thought it was locked. Interview with the Director of…

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 of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Review of facility documentation and observations identified Resident #1 and #2 shared a room. a. Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, anxiety disorder, and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required extensive assistance of two (2) with bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 8/25/2023 identified Resident #1 required staff assistance with ADL's. Interventions directed to assist as needed to meet toileting needs, provide incontinent care per policy and assist with transfers per MD…

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 of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff provided care in accordance with the resident plan of care. The findings include: Resident #1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, anxiety disorder, and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required extensive assistance of two (2) with bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 8/25/2023 identified Resident #1 required staff assistance with ADL's. Interventions directed to assist as needed to meet toileting needs, provide incontinent care per policy and assist with transfers per MD orders. Review of Resident #1's care card directed for toileting, transfers, 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 clinical record review, facility documentation review, facility policy review, and interviews for one of five employee file reviews (NA #1), the facility failed to ensure abuse education was provided and documented timely for a full-time personnel. The findings include: Review of facility documentation identified NA #1 was a full-time staff member in the facility from 10/27/2022 until 7/23/2023, then went per diem until her resignation. Additional review failed to identify resident abuse education was provided for NA #1. Review of NA #1's on-boarding/hire check list identified Resident Abuse, COVID-19, and Cognitive Impairment test education were not performed. Review of NA #1's employee file orientation checklist dated 10/27/2022 identified Abuse/Restraint Free Philosophy was not reviewed, and NA #1 was not signed off by an administrator or orientation coordinator. Interview with the DON on 10/4/2023 at 2:30 PM identified all the documentation provided was all the documents the facility had regarding NA #1's education competencies for abuse. Although the DON indicated 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 clinical record review, facility documentation, facility policies and interviews for one sampled resident (Residents #1) who was reviewed for an allegation of mistreatment, the facility failed to treat a resident in a manner that maintained the resident's respect and dignity. The findings include: Resident #1's diagnoses included vascular dementia with behavioral disturbance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some short- and long-term memory deficits, required extensive two (2) person assistance with turning and repositioning while in bed and getting in and out of the bed and chair, and extensive one (1) person assistance with personal hygiene and dressing. The Resident Care Plan dated 6/30/23 identified Resident #1 had impaired memory, recall and decision-making skills. Interventions directed to allow time to respond when speaking to the resident, offer one step at a time directions, use short simple sentences. The Facility Reported Incident 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 review of the clinical record, facility documentation, facility policy and procedures and interviews for one of two residents reviewed for dialysis (R# 50), the facility failed to ensure the resident who required dialysis receive such services in a consistent and or professional standard of practice. The findings included: Resident #50's diagnoses included, end stage renal disease, vascular dementia without behavioral disturbance, diabetes mellitus and hypertension. A quarterly assessment dated [DATE] identified the resident as moderately impaired for decision-making skills, requiring limited assistance of staff for most activities of daily living and is always steady for balance during transition and walking with an assistive device. The RCP updated on 11/3/21 identified dialysis due to chronic renal disease as the focus. Interventions included hemodialysis 3 times weekly, any questions regarding the resident ' s care contact the dialysis center, labs as ordered in facility and/or at dialysis center,…

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, facility documentation review and interviews during the medication storage and labeling review for three of three medication rooms (North, [NAME] and East Units) the facility failed to ensure medications were stored safely in the medication refrigerator. The findings include: Review of the North medication storage area on 12/28/21 at 9:10 AM with RN #1 identified that the medication refrigerator temperature was observed at 32 degrees. The north medication storage area temperature log lacked documentation of recorded temperatures for 5 days in December (12/23 to 12/27). There was 1 vial of insulin and 1 vial of Lorazepam stored in the refrigerator. Additionally, the temperature recorded for 8 of the daily checks in October and for 14 of the daily checks in the temperature recorded was below 36 degrees. Although requested the facility was unable to provide a completed North medication refrigerator log for the month of November. Interview with RN #1 on 12/28/21 at 9:10 AM identified that he was new and was not sure how often the medication refrigerator…

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.