Apple Rehab Laurel Woods

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 fully investigate an allegation of misappropriation of money to include obtaining statements from the accused, other staff, other residents and/or resident representatives to ensure all residents were free from misappropriation in accordance with facility policy. The findings include: Resident #1's diagnoses included acute respiratory failure with hypercapnia (when the body can't remove excess carbon dioxide from the bloodstream causing it to build up) and cognitive communication deficit. The Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented with good memory recall and required a two (2) person assist for transfers and ambulation and was independent with bed mobility and positioning. The baseline Resident Care Plan (RCP) dated 2/14/25 identified Resident #1 required assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for personal care and assistance, the facility failed to ensure documentation was complete in the clinical record. The findings include: Resident #2's diagnoses included type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels), congestive heart failure (when the heart cannot pump blood efficiently enough to give your body a normal supply), obesity and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition and required setup assistance with eating, substantial assistance with toileting hygiene, showering/bathing self, personal hygiene, bed mobility and transfers. Additionally, it identified that Resident #1 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urethra 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 clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure Resident #1 was not verbally abused by staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Resident Care Plan dated 2/20/25 identified Resident #1 required assistance with incontinent care. Interventions directed to assist the resident with incontinent care timely and assist the resident in and out of bed during the day. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset…

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 (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident verbal abuse, the facility failed to report the allegation of verbal abuse to the Administrator and/or designee within two (2) hours after the event was reported by the resident to facility staff. The findings include: Resident #1's diagnoses included schizoaffective disorder, cognitive communication deficit, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had some memory recall deficits, had not exhibited behavioral symptoms, and was dependent on staff for toileting. The Facility Reported Incident form dated 3/2/25 identified at 3:40 PM Resident #1 reported having an interaction with an 11PM-7AM nurse aide, Nurse Aide (NA) #1, on 3/2/25 that upset him/her. Resident #1 requested that NA #1 no longer provides care for him/her. The nurse's note dated 3/3/25 at 2:02 PM…

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 Leave of Absence (LOA), the facility failed to ensure a resident who is dependent on staff for transfers, Activities of Daily Living (ADLs) and severely impaired cognition was accompanied to a medical appointment out in the community, resulting in the resident being dropped off at the wrong location, then dropped off by an unknown person to the emergency department. The findings include: Resident #1 had diagnoses that included mild cognitive impairment, seizures, diabetes mellitus, peripheral vascular disease, and bipolar disorder. The clinical record failed to identify an LOA order. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) indicative of severely impaired cognition, has impaired vision, dependent with ADLs and transfers. The care plan dated 10/8/24 identified Resident #1 needs…

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 documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #1 was admitted with diagnoses that included stroke with resultant left sided hemiplegia (inability to move the left side of the body), anxiety and depression. An admission MDS assessment dated [DATE] identified that Resident #1 was alert and oriented, and was independent for transfers and mobility with a wheelchair. The RCP dated 6/11/2024 identified Resident #1 was in the facility for short term rehabilitation and needed orientation to facility and new surroundings. The RCP directed to check in to see if there was anything to assist adjustment to new environment and to be aware of mood and behaviors. A facility incident report dated 8/19/2024 accident and investigation report dated 8/19/2024 at 11:00 AM identified an allegation 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 documentation, facility policy, and interviews for three (3) of four (4) residents (Resident #1, Resident #3, and Resident #4) reviewed for elopement risk, the facility failed to complete the elopement risk assessment in a timely manner in accordance with facility policy. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, adjustment disorder and delusional disorders. An elopement risk evaluation dated 8/24/23 identified Resident #1 was at risk for elopement (8 months since the last assessment was completed). A physician's order dated 1/20/24 directed wander guard to left ankle and under seat of rolling walker, check placement every shift and check function every night shift. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition and was independent with ambulation with a device. The care plan dated 2/27/24 identified Resident #1 was at risk for elopement from the building due 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.

Based on review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure the facility exit doors equipped with a wander guard system were checked daily. The findings include: Review of the accident and incident form (A&I) dated 5/19/24 identified on 5/19/24 at 6:15 PM Resident #1 was found outside walking towards the police station. Resident #1 was wearing his/her wander guard on his/her right ankle. The wander guard was tested, and the front door alarmed but did not lock. Review of the audit forms for facility doors for the month of May 2024 identified on the weekends; 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/18/24 and 5/19/24 (day of event) there were no door checks completed and documented. Interview with RN #1 on 5/22/24 at 12:43 PM identified when Resident #1 was brought back into the facility she tested the front doors with three (3) wander guards and the door alarmed but did not lock. RN #1 identified she did not call maintenance because she was informed the team would take care of it in the morning. Interview with Maintenance…

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, facility policy, and interviews for 6 of 7 personnel files reviewed, the facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides prior to hire. The findings include: Review of NA #2's personnel file identified that she was hired on 9/1/21 and failed to contain documentation that the required background checks were completed. Review of NA #4's personnel file identified that she was hired on 9/2/22 and failed to contain documentation that the required background checks were completed. Review of RN #7's personnel file identified that she was hired on 7/18/20 and failed to contain documentation that the required background checks were completed. Review of LPN #10's personnel file identified that she was hired on 3/29/23 and failed to contain documentation that the required background checks were completed, including fingerprinting.1. Employee File for LPN #8 identified he started working for the facility on 12/27/22 and was terminated on 2/20/23 with the last day worked on 2/15/23.…

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.

Based on observation, facility documentation, facility policy, and interviews reviewed for Dietary Services , the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings include: A tour of the Kitchen on 3/7/24 at 9:10 AM with [NAME] #1 identified in the walk in refrigerator; 4 pancakes in a zip lock bag not labeled or dated, 2 large rectangle deep metal pans on 3/4 full of salad mix and one almost empty salad mix neither was not labeled or dated, a large rectangle deep metal pan a third full with scoop marks out of the puree pancake mix not labeled but dated 2/29, a large rectangle deep metal pan with puree eggs not labeled but dated 3/3, a square deep metal pan half full with a brown liquid appeared jelly thickness not labeled or dated, 3 large plastic containers with green lids with dices fruit were not labeled or dated, 15 chocolate chip cookies in a plastic bag were not labeled or dated, and a pie with tin foil over the top with some missing was not labeled or dated. Interview with the [NAME]…

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 2 of 26 residents (Resident #43 and Resident #315) reviewed for advance directives, the facility failed to accurately document the resident's life support choices and/or failed to ensure advanced directives were reviewed with a newly admitted resident. The findings include: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses which included enterocolitis due to clostridium difficile, hemiplegia and hemiparesis following cerebrovascular disease, and heart failure. The signed advance directive consent form dated [DATE] identified the conservator of Resident #43's choice regarding life support systems elected for Resident #43 to receive cardiopulmonary resuscitation (CPR). The admission MDS assessment dated [DATE] identified Resident #43 had severely impaired cognition. The hospital Discharge summary dated [DATE] identified Resident #43 was admitted to the hospital on [DATE]; on [DATE] a meeting was held 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #66) reviewed for pressure ulcers, the facility failed ensure the APRN/physician and resident representative were notified, of a newly identified skin blister, in a timely manner.The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses which included dementia, severe protein-calorie malnutrition, and adult failure to thrive. The annual MDS assessment dated [DATE] identified Resident #66 had severely impaired cognition, was at risk for developing pressure ulcers/injuries, was always incontinent of bowel and bladder, and was dependent on staff for chair/bed-to-chair transfers and rolling left to right. The care plan dated 1/26/24 identified Resident #66 was at risk for alterations in skin integrity related to incontinence of bowel and bladder, severe malnourishment, and failure to thrive. Interventions included to inspect skin for signs and symptoms of breakdown including bruising,…

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 documentation, and interviews for one resident (Resident #20) reviewed for misappropriation of resident property, the facility failed to ensure the resident was free from misappropriation of an ordered (Scheduled II Controlled Drug) medication. The findings include: Resident #20 was admitted to the facility in December 2022 with diagnoses which included Alzheimer's disease, vascular dementia with behavioral disturbance, and vascular dementia with agitation. Review of the Controlled Substance Disposition Record (CSDR) dated 5/19/23 for Morphine Sulfate 100 mg/5 ml Solution take 0.25 ml (5 mg total) by mouth every 3 hours as needed for moderate pain or severe pain and shortness of breath. Maximum daily amount of 40 mg. Review of the Controlled Substance Disposition Record (CSDR) dated 5/19/23 for Morphine Sulfate 100 mg/5 ml Solution for Resident #20. Identified on 12/3/23 at 9:15 AM 0.25 ml was borrowed for another resident with 2 licensed staff…

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 3 residents (Resident #31) reviewed for abuse, the facility failed to ensure the local law enforcement was notified of a staff to resident abuse per facility policy. The finding include: Resident #31 was admitted to the facility with diagnoses which included dementia, tramatic brain injury, and dysphasia. A physician's order dated 12/16/22 directed when out of bed Resident #31 was to sit in an adaptive tilt in space wheelchair with specialty cushion with bilateral elevating leg rests and a head support via standing mechanical lift with assist of 2. Reposition every 2 hours and sit upright for meals. The annual MDS assessment dated [DATE] identified Resident #31had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with toileting and eating and required total assistance with personal hygiene, dressing, bed mobility and transfers. Additionally, 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 review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #10, #16 and #31) reviewed for care planning, the facility failed to have a comprehensive social worker assessment admission, quarterly, and annual completed timely. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, anxiety, major depression, and paranoid schizophrenia. Review of the clinical record dated 3/17/22 - 3/14/24 identified 1 social services assessment completed on 1/29/24. The admission assessment dated [DATE] at 1:48 PM identified Resident #10 was transferred from another facility on 3/17/22 at 2:30 PM for long term care. admission assessment did not reflect a social services assessment was completed. The care plan dated 4/3/22 identified Resident #10 was admitted for long term care. Interventions included to provide social services to provide opportunities to express concerns as needed. 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 documentation and interviews for 1 of 5 residents (Resident #5) reviewed for PASARR, the facility failed to ensure the PASARR was updated when there was a change in condition. The findings include: Resident #5 PASARR dated 3/23/17 identified a diagnosis of schizoaffective disorder and major depression. PASARR indicated Resident #5 does not have a diagnosis of dementia or Alzheimer's disease. Resident #5 was admitted to the facility on [DATE] with diagnoses which included dementia, major depression, and schizoaffective disorder. The hospital Discharge summary dated [DATE] identified Resident #5 had a diagnosis of schizoaffective disorder, diabetes, and dementia. A physician's order dated 6/24/21 directed Divalproex (used for schizoaffective disorder) 750 mg extended release in the morning and Divalproex 1000 mg delayed release at bedtime, Perphenazine (used for schizoaffective disorder) 4 mg tablet twice a day, Duloxetine (depression) 90 mg daily. The physician…

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 3 residents (Resident #10 and #48) reviewed for accidents, the facility failed to ensure the neurological assessments were completed after multiple falls and for 1 resident (Resident #16) reviewed for hospice, the facility failed to ensure there was a physician order for hospice services and 1 of 2 residents (Resident #66) reviewed for pressure ulcers, the facility failed ensure an RN assessment was completed for a newly identified skin blister and for 1 of 7 residents (Resident #104) reviewed for nutrition, the facility failed to follow the physician's orders to obtain repeated labs for a resident with an abnormal blood count and for 2 of 7 ( Resident #2 and Resident#315) reviewed for nutrition, the facility failed to obtain weights according to facility policy. The findings include: 1. Resident #10 was admitted to the facility with diagnoses which included paranoid schizophrenia, schizoaffective disorder,…

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 7 residents (Resident #94) reviewed for nutrition, the facility failed to ensure that weights were monitored per physician's order for a resident with a significant weight loss. The findings include: Resident # 94 was admitted to the facility on [DATE] with diagnoses which included stroke, hypertension, and diabetes. The APRN note dated 3/6/23 identified Resident #94 did not require medication or blood glucose monitoring for diabetes. A physician's order dated 3/9/23 directed for weekly weights and vital signs to be obtained every Friday day shift. The quarterly MDS assessement dated 3/16/23 identified Resident # 94 had moderately impaired cognition, and required supervision with eating. The care plan dated 3/16/23 directed that Resident #94 had a potential for nutritional decline related to medical history. Interventions included obtaining weights as ordered. The nutritional 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.

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 2 of 2 residents (Resident #49 and #268) reviewed for respiratory care, the facility failed to ensure (Resident #49)respiratory equipment was labeled, dated, and stored per policy when not in use and (Resident # 268) failed to maintain BiPaP tubing in a sanitary manner. The findings include: 1. Resident #49 was admitted to the facility with diagnoses which included dementia, hypertension, and Covid-19. The quarterly MDS assessment dated [DATE] identified Resident #49 had severely impaired cognition and requires total assistance with oral hygiene, bathing, and personal hygiene. The care plan dated 2/13/24 identified Resident #49 has pneumonia. Interventions included to use oxygen and oxygen saturation levels as ordered. Additionally, respiratory modalities per physician orders. A physician's order dated 2/13/24 directed to apply oxygen between 1-5 liters per minute to maintain oxygen level greater than…

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, facility policy, and interviews for 1 of 2 certified nurse aide personnel files reviewed, the facility failed to complete annual employee performance reviews. The findings include: Review of NA #2's personnel file identified she was hired on 9/1/21, and no performance review was completed for the year of 2023. Interview with the DNS on 3/14/24 at 8:28 AM identified that certified nurse aide performance reviews are expected to be completed annually. The DNS further identified that she had begun her employment at the facility in July of 2023 and had identified that there were employee performance reviews that had not been completed in years. The DNS indicated that she has developed a plan to complete all the outstanding 2023 certified nurse aide performance reviews, with the assistance of a nursing supervisor. The DNS further indicated that once she has completed all the 2023 reviews, she will devise a calendar that will aid her in scheduling and completing annual performance reviews based on the employee's date of hire, for the year ahead.…

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 clinical record, review of policy, and interviews for two of five residents reviewed for unnecessary medications (Resident #10, and Resident #74), the facility failed to document and monitor specific behaviors with the use of antipsychotic medication. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, anxiety disorder, and sleep disorder. The quarterly MDS assessment dated [DATE] identified Resident #10 had moderately impaired cognition, identified no behaviors, and required total dependent with personal hygiene. The care plan dated 1/29/24 identified Resident #10 was at risk for an alteration in mood and behaviors, I have multiple psych diagnoses. Interventions included provide medication as prescribed by physician. Be aware of changes in my mood/behavior and notify the physician. Psych evaluation and follow up as ordered and needed. The care plan dated 1/29/24 identified Resident #10…

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 3 residents (Resident #48) reviewed for accidents, the facility failed to ensure clinical record reflected complete and accurate documentation related to neurological checks and RN assessments following unwitnessed falls. The findings include: Resident # 48 was admitted to the facility on [DATE] with diagnoses included dementia, repeated falls, and psychophysical visual disturbances. A nursing note dated 9/2/23 at 9:11 PM completed by RN #10 identified Resident #48 had no change in condition. The note further identified that Resident #48 was admitted to the facility on [DATE] at 2:55 PM and fell at 3:15PM onto his /her buttocks his/her buttocks but did not hit his/her head, was confused at baseline, and was unable to follow simple commands, and was oriented to his/her room prior to the fall. A nursing note dated 9/2/23 at 9:51 PM completed by RN #10 identified that Resident #48 was admitted to 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #16) reviewed for Hospice, the facility failed to have compete medical record with the hospice election form and the physician certification of terminal illness specific to Resident #16. The findings include: Resident #16 was admitted to the facility with diagnoses which included Alzheimer's disease and dementia. The care plan dated 7/24/23 identified Resident #16 was receiving hospice care. Interventions included to provide emotional support to the resident and family. The significant change of condition MDS assessment dated [DATE] identified Resident #16 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required extensive assistance with bed mobility, toileting, and personal hygiene. Additionally, needed limited assistance with transfers, dressing, and locomotion on and off the unit and was receiving Hospice services. Interview…

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 review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure adequate supervision for a resident known to have severe cognitive impairment and a risk for elopement. Resident #1 left the facility without staff knowledge, unescorted, unsupervised and was observed on the sidewalk next to the building. The findings include: Resident #1's diagnoses included vascular dementia, Alzheimer's disease, malignant neoplasm of colon, and anxiety disorder. The Nursing Evaluation for Elopement Risk performed on 7/6/2023 identified Resident #1 as an elopement risk related to cognitive impairment, seeking out exit areas and leaving the unit without staff knowledge. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had severely impaired cognition and required supervision with an assistive device for locomotion. The Resident Care Plan dated 7/26/2023 identified Resident #1 frequently…

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 accidents, the facility failed to ensure a resident identified at risk for choking was supervised during a meal in accordance with the plan of care. The findings include: Resident #1's diagnoses included dysphagia (difficulty swallowing), Barret's esophagus (damage to the swallowing tube due to acid reflux), schizoaffective disorder, and weakness. The Resident Care Plan dated 6/5/3023 identified Resident #1 had a diagnosis of dysphagia. Interventions directed to offer to set up for meals and to provide a mechanically soft diet as ordered. A physician's order dated 6/13/2023 directed a regular diet/regular texture and mild thick liquids - nectar consistency. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had mild cognitive impairment and required one (1) staff member for extensive assistance when eating. A 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 observation, review of facility documentation, review of facility policy, and interviews, the facility failed to monitor refrigerator temperatures in 3 of 3 medication rooms according to facility policy and/or store medications under proper temperature controls for Residents #2, 4, 11, 14, 25, 36, 46, 53, 61, 69, 72, 73, 76, 78, 94, and 200. The findings include: a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, peripheral vascular disease (PVD), and Congestive Heart Failure (CHF). A physician's order for Resident #2 dated 01/07/2020, directed administration of Performist 20 mcg/2ml via nebulizer every 12 hours. b. Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus without complications, morbid obesity, and CHF. A physician's order dated 12/16/19, directed 1.5 mg Trulicity be administered subcutaneously to the resident every Sunday. Additionally, a physician order dated 12/20/19…

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, review of facility policy, and interviews for one of two residents (Resident #45), reviewed for pain management the facility failed to notify Physician that a medication was not administered for three consecutive doses. The findings include: Resident #45 had diagnoses which included Malignant Neoplasm of Prostate, Colostomy, Hemiplegia & Hemiparesis, affecting right dominant side, hydronephrosis, and anxiety. The Quarterly Minimum Data Sheet (MDS) dated [DATE] identified Resident #45 as alert and cognitively intact, requiring one person assist for Activities of Daily Living (ADL's) and transfers to a manual wheelchair. Resident #45 required set up for meals and was able to self propel in a manual wheelchair. The Quarterly Resident Care Plan (RCP) dated 10/25/2019 identified Resident #45, as at risk for pain, with complaints of abdominal pain, left hip abscess, and pain around stomas. The RCP identified that Resident #45 will report any pain and identified interventions…

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 documentation, and review of facility policy, for one of two residents (Resident #150) reviewed for abuse, the facility failed to protect a resident's right to be free from misappropriation of resident property. The findings include: Resident #150 was admitted to the facility on [DATE] with diagnoses including dementia, subdural hemorrhage, major depressive disorder, dysphagia, and monoplegia of upper limb affecting right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #150 had moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance with dressing and personal hygiene. The care plan dated 5/14/19 identified Resident #150 was confused and forgetful due to advancing age and recent hospitalization. Resident #150 was also more lethargic since return from the hospital. Interventions included to allow time for responses when speaking to the resident, offer…

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, review of facility policy, and interviews, for one of two Residents (Resident #45) reviewed for pain management, the facility failed to administer pain medication per physician's orders. The finding include: Resident #45 had diagnoses including Malignant Neoplasm of Prostate, Colostomy, Hemiplegia & Hemiparesis, affecting right dominant side, hydronephrosis, and anxiety. The Quarterly Minimum Data Sheet (MDS) dated [DATE] identified Resident #45 as alert and cognitively intact, requiring one person assist for Activities of Daily Living (ADL's) and transfers to a manual wheelchair, required set up for meals, and was able to self propel in a manual wheelchair. The Quarterly Resident Care Plan (RCP) dated 10/25/2019 identified Resident #45 as at risk for pain, with complaints of abdominal pain, left hip abscess, and pain around stomas. The RCP identified that Resident #45 will report any pain. Interventions included administer scheduled pain…

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, review of facility policy, and interviews, for one of five sampled residents (Resident #94) reviewed for unnecessary medications, the facility failed to ensure a pharmacy recommendation was acted upon in a timely manner. The findings include: Resident #94's diagnoses included diabetes mellitus and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #94 was severely cognitively impaired and required extensive assistance with Activities of Daily living (ADL's). The Resident Care Plan (RCP) dated 9/17/19 identified Resident #94 was at risk for cardiac issues related to hypertension. Interventions directed to check Resident #94's blood pressure as ordered, notify the physician/Advanced Practice Registered Nurse (APRN) if not within established parameters. A physician's order dated 9/28/19 directed to administer doxazosin mesylate 1 mg by mouth at bedtime. The pharmacy consultant report 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.