Apple Rehab Coccomo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and review of the facility Quality Assurance and Performance Improvement (QAPI), the facility failed to recognize and put measures in place to ensure neurological assessments were completed for a resident with a significant amount of falls (Resident #56). The findings include: Resident # 56's diagnosis included Parkinson's disease, peripheral vascular disease, and hypertension.Resident #56 was admitted to the facility on [DATE].A nursing admission assessment (the admission Minimum Data Set assessment had not yet been completed) dated 1/29/25 identified Resident #56 was severely cognitively impaired and required assistance of 2 for bathing, transferring and personal care.The Resident Care Plan (RCP) dated 2/2/25 identified Resident #56 was at risk for falls due to multiple risk factors with intervention to toilet Resident #56 prior to dinner, encourage Resident #56 to ask and wait for staff assistance for transfers and/or toileting.a. A facility Accident and Incident report dated 2/2/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and interviews for 5 resident private bathrooms and 4 resident shared bathrooms on 3 of 3 nursing units, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy. The findings included: Based on observation, review of facility policy and interviews for 5 resident private bathrooms and 4 resident shared bathrooms on 3 of 3 nursing units, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy. The findings included: Observation on 7/28/25 at 11:00 AM and observation and interview with the Infection Prevention (IP) Registered Nurse (RN) #2 on 7/30/25 at 11:49 AM identified the following on Unit 100: room [ROOM NUMBER]'s private bathroom contained one bedpan that was unlabeled, uncovered and located on the bathroom floor next to the toilet. room [ROOM NUMBER]'s private bathroom contained one bedpan that was unlabeled, uncovered and located…

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 24 residents (Resident #27 and Resident #45) reviewed for advance directives (a written statement of a resident's wishes regarding medical treatment), the facility failed to obtain a physician's order for advance directives for Resident #27 and failed to ensure advanced directives were discussed and necessary documentation completed regarding advanced directives for Resident #45. The findings include:1.Resident #27 had diagnoses that included dementia, anxiety, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 was severely cognitively impaired and independent with eating, transfers, and ambulation. The Resident Care Plan (RCP) dated 4/21/25 identified Resident #27 required staff assistance with activities of daily living. Interventions included advanced directives per physician orders. A Medical Interventions Form (advance directives) signed by Resident #27's responsible party 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 interviews, observation, review of the clinical record, facility documentation, and facility policy for 1 of 4 residents (Resident #88) reviewed for medication administration, the facility failed to notify the provider of medication omissions. The findings include:Resident #88's diagnoses included unspecified dementia, alcohol abuse with withdrawal, and Gastro-Esophageal Reflux Disease (GERD) with esophagitis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #88 was moderately cognitively impaired, was independent for self-care and dependent on staff for chair/bed-to-chair transfers.The Resident Care Plan dated 7/11/25 identified Resident #88 had alcohol use/abuse. Interventions included dietary consultations as needed to ensure adequate nutrition/ hydration and to provide medications as ordered.A physician's order dated 5/1/25 directed to administer B12 active oral chewable tablet (Methylcobalamin) by mouth in the morning for vitamin supplement related to alcohol abuse 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 #84) reviewed for position/mobility, the facility failed to formulate a baseline care plan (BCP) that addressed all required areas, failed to document a timely completion of the BCP meeting, failed to document the resident/resident representative participated in the BCP and that a BCP summary was provided to the resident/resident representative. The findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, obstructive sleep apnea, and morbid obesity.The Nursing admission assessment dated [DATE] at 3:05 PM identified Resident #84 was cognitively intact, required assistance with eating, was dependent for bed mobility, and required the assistance of 2 staff members for transfers with a mechanical lift.a. Review of a handwritten BCP dated 3/31/25 identified Resident #84 was alert and was admitted for long-term care with a primary goal of remaining long term in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews and facility policy for 1 of 4 sampled residents (Resident #56) reviewed for accidents, the facility failed to complete neurological assessments after a fall, per facility policy for unwitnessed falls and for 1 of 1 sampled resident observed with medications at the bedside (Resident #88), the facility failed to administer medications according to standards of practice. The findings include:1.Resident # 56's was admitted to the facility on [DATE] with diagnosis that included Parkinson's disease, peripheral vascular disease, and hypertension. A nursing admission assessment (the admission Minimum Data Set assessment had not yet been completed) dated 1/29/25 identified Resident #56 was severely cognitively impaired and required assistance of 2 for bathing, transferring and personal care. The Resident Care Plan (RCP) dated 2/2/25 identified Resident #56 was at risk for falls due to multiple risk factors with intervention to toilet Resident #56 prior to dinner, encourage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility documentation, and interviews for 1 of 1 sampled resident (Resident #56) reviewed for edema, the facility failed to follow physician orders for applying compression stockings. The findings include:Resident # 56's diagnosis included Parkinson disease, peripheral vascular disease, and hypertension.The Resident Care Plan dated 4/16/25 identified Resident #56 had bilateral, pitting edema, interventions included to notify the physician if extremities become blue, red, swollen, hot, or any skin issues. Also, to encourage and assist Resident #56 to change position frequently.Review of the physician orders dated 4/23/25 directed to apply compression stockings in the AM and remove at hours of sleep every day and evening shift for edema.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #56 as severely cognitively impaired and was independent for eating. Also, identified Resident #56 was dependent on oral hygiene, showering, and dressing. Further,…

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 the observations, facility policy, record review, and interviews for 1 of 1 sampled resident (Resident #88) observed on tour to have medication at the bedside, the facility failed to properly secure medications. The findings include:Resident #88's diagnosis included dementia, depression and anxiety disorder.The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #88 was moderately cognitively impaired and was independent with personal hygiene, bathing, transfers, and toileting.The Resident Care Plan dated 7/11/25 identified Resident #88 having dementia with impaired memory, recall and decision-making skills. Interventions included to use simple terms and offer gentle reminders.Physician orders dated 7/20/25 directed the following medications were ordered and scheduled for administration at 8:00 AM and 9:00 AM:1. Buspirone (a medication to treat depression) 10 milligram (mg) tablet, give 1.5 tablets (15 mg dose) by mouth every morning2. Pantoprazole (a medication to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #7) reviewed for accidents, the facility failed to ensure the Resident Care Plan (RCP) was revised upon readmission to the facility, to direct the updated transfer status, after the resident sustained a facility acquired fracture due to a fall. The findings include: Resident #7's diagnoses included chronic obstructive pulmonary disease, depression and benign paroxysmal vertigo (crystals in ear that disrupt normal fluid flow causing false sense of motion and brief episodes of dizziness). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of ten), was dependent for shower transfers, required set up/clean up assistance with bed mobility and lower body dressing, was independent with bathing, upper body dressing, personal hygiene, transfers, ambulation of ten feet or less and 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.

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 intravenous antibiotic therapy, the facility failed to secure an order to flush the intravenous line to ensure the entire dose of medication was administered. The findings include: Resident #1's diagnosis included bilateral ankle osteomyelitis, an infection of the bone. A physician's order dated 1/24/25 directed to administer ceftriaxone 2 Grams intravenously one (1) time a day and to flush the lumen with 10 milliliters (ml) before medication and 10ml after medication then 3ml of Heparin. The Advanced Practice Registered Nurse acceptance note dated 1/25/25 identified Resident #1 was alert and oriented to person, place, and time and was admitted for continued intravenous antibiotic therapy. Review of the January 2025 Medication Administration Records failed to reflect an order to flush the intravenous tubing after the ceftriaxone was administered to ensure Resident #1 received the full dosage of antibiotics had been…

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 two residents (Resident #3) reviewed for abuse, the facility failed ensure the resident was free from verbal mistreatment. The findings include: Resident #3 was admitted with diagnoses that included attention and concentration deficit and asthma. A quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS of 11 indicating moderately impaired cognition and required assistance with ALDs. A resident care plan dated 9/10/2024 identified Resident #3 had ineffective coping with accusatory behaviors due to cognitive impairment. Interventions included assist of two (2) staff with care, explain all procedures, speak simply and to offer support and reassurance. A facility reportable event (RE) form dated 11/11/2024 at 7:04 PM identified on 11/10/2024 at 12 PM, Person #3 reported LPN #3 had made inappropriate comments to Resident #3. An RN assessment identified no injuries, LPN #3 was suspended…

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 two residents (Resident #3) reviewed for abuse, the facility failed ensure staff reported an allegation of abuse timely, and the facility failed to notify the State Agency timely when it became aware of an allegation of abuse. The findings include: Resident #3 was admitted with diagnoses that included attention and concentration deficit and asthma. A quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS of 11 indicating moderately impaired cognition and required assistance with ALDs. A resident care plan dated 9/10/2024 identified Resident #3 had ineffective coping with accusatory behaviors due to cognitive impairment. Interventions included assist of two (2) staff with care, explain all procedures, speak simply and to offer support and reassurance. A facility reportable event (RE) form dated 11/11/2024 at 7:04 PM identified on 11/10/2024 at 12 PM, Person #3 reported LPN #3 had made…

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 #2) reviewed for wounds, the facility failed to ensure the resident care plan was revised timely to include resident refusals of wound care. The findings include: Resident #2's diagnoses included a non-pressure chronic left foot ulcer and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and had two (2) unstageable diabetic ulcers, had pressure reducing devices, and received nutrition and ointments/medication for pressure ulcer/injury care. The Resident Care Plan (RCP) dated 9/19/2024 identified Resident #2 was at risk for skin breakdown due to decreased mobility, incontinence, poor nutrition, poor circulation, pronounced body prominences, and altered sensation. Interventions directed use of 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 one of three residents (Resident #2) reviewed for wounds, the facility failed to act timely on a wound consultant order, and failed to ensure a low air-loss mattress was maintained in place in accordance with wound consultant orders. The findings include: Resident #2's diagnoses included a non-pressure chronic left foot ulcer and diabetes mellitus. Review of the Wound Center Physician Notes and Orders dated 9/11/2024 identified Resident #2 had a left lower extremity unstageable ulceration and a left lower extremity ankle/Achilles stage four (4) ulceration. The wound center orders directed Resident #2 required pressure relief devices to include waffle booties, pressure relief cushion on wheelchair (ROHO), and a low air-loss mattress. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen (08/15),…

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 quality of care, the facility failed to perform an elopement risk assessment after a resident returned to the facility after an identified unauthorized absence and the facility failed to accurately complete an elopement risk assessment after an unauthorized resident absence. The findings include: Resident #1's diagnoses included metabolic encephalopathy, dementia, depression, and anxiety disorder, and a history of alcohol abuse. The Resident Care Plan (RCP) dated 11/18/2024 identified Resident #1 had impaired memory, impaired recall and impaired decision-making skills related to dementia. Interventions directed to orient to room/staff, offer support and reassurance, and gentle reminders when resident is confused or forgetful. Record review identified Resident #1 was responsible for him/herself (had no Power of Attorney or court appointed Conservator). Review…

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

Based on observations and interviews for 2 of 3 resident units, for Resident #'s 3, 10, 15, 20, 22, 23, 35, 42, 43, 46, 53, 57, 58, 61, 62, 63, 81, 82, and 83 who were reviewed for the environment, the facility failed to maintain a functional and sanitary environment for residents. The findings include: Intermittent observations on 9/25/23 between 10:30 AM and 2:00 PM, identified toilets with continually circulating water and faucets with dripping water in multiple resident bathrooms on the 200 and 300 units. Resident #'s 3, 10, 15, 20, 22, 23, 35, 42, 43, 46, 53, 57, 58, 61, 62, 63, 81, 82, and 83's bathrooms were observed to be effected. Additionally, in Resident #35's bathroom, an active, almost constant flow of water was noted to be coming through the ceiling vent and emptying into a trash can. Several areas of the ceiling surrounding the vent were noted to be dry and peeling, with some areas wet and leaking. Interview with Resident #35 on 9/25/23 at 12:29 PM identified that the leak in and around the bathroom ceiling vent had been occuring on and off for several weeks. 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 clinical record review, facility policy and staff interview for 1 of 1 sampled residents (Resident #56) reviewed for advanced directives, the facility failed to ensure Resident #56 signed the Advanced Directive Consent form. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included hypotension, chronic obstructive pulmonary disease, and generalized anxiety. Face Sheet documentation located in the clinical record identified Resident #56 was responsible for him/her self. A Medical Interventions Consent form dated 9/3/23 and signed by Person #1 identified Resident #56's code status was Do Not Resuscitate (DNR)/Do Not Intubate (DNI) but failed to include Resident #56's signature despite Resident #56 being responsible for him/herself. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 was cognitively intact and required limited assistance of one person with transfer, dressing, toilet use, and personal hygiene. A written 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 FACILITY Environment Based on observations, facility policy and interviews for 5 observed residents, Resident #11, 15, 22, 29, and 53, who were using the resident television lounge, the facility failed to maintain a homelike environment in 2 of 3 resident areas. The findings include: Observation of the 300 Unit Television Lounge on 9/26/23 at 10:40 AM identified 10 wheelchairs (5 standard and 5 adaptive/custom wheelchair), 2 mechanical lift devices, and 1 [NAME] chair. Two residents (Resident #11 and #15) were noted to be using the television room for leisure. Interview with the ADNS on 9/26/23 at 9:40 AM identified that it appears wheelchairs and lifts were being stored in the television room, but that storage did not usually occur in that area. The ADNS indicated that she had not witnessed equipment stored in this area before. The ADNS identified that medical equipment storage should not occur in resident areas. Interview with NA #2 on 9/26/23 at 9:48 AM identified that the facility has been storing…

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 policy, and interview for 1 of 5 sampled residents, Resident #30, reviewed for medications, the facility failed to develop a comprehensive care plan for anticoagulation (blood thinners). The findings include: Resident #30's diagnoses included atrial fibrillation and atherosclerotic heart disease. A physician's order dated 9/18/23 directed to administer Apixaban (blood thinner) oral tablets 5 milligrams daily for atrial fibrillation. Review of the baseline Resident Care Plan (RCP) dated 9/18/23 failed to identify Resident #30 had a care plan to monitor his/her condition while on blood thinners. Interview and review of the RCP on 9/28/23 at 11:30 AM with RN #3 (MDS Coordinator), identified that all residents being administered blood thinners should have a comprehensive care plan related to anticoagulation. RN #3 indicated that she was responsible for the development of comprehensive care plans but was unable to identify why there was no care plan related to blood thinners. Review of the Care Planning policy dated 2019 directed, in part,…

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 interview for 1 of 5 residents, Resident #35, reviewed for unnecessary medications, the facility failed to develop a comprehensive care plan while on anticoagulation (blood thinners). The findings include: Resident #35's diagnoses included presence of left artificial hip joint and atherosclerotic heart disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #35 was moderately cognitively impaired and required extensive assistance of 2 staff for bed mobility and transfers. The Resident Care Plan (RCP) dated 6/29/23 identified no care plan for blood thinners. A physician's order dated 6/6/2022 directed staff to administer Apixaban tablet, 2.5 milligrams, two times a day, by mouth. Interview and review of Resident #35's clinical record with LPN#1 on 9/27/23 at 11:05 AM identified that, although she monitors Resident #35 for signs of bleeding due to being on a blood thinner, LPN #1 was unable to show nursing documentation or 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 of two residents (Resident #31 and Resident #59) reviewed for accidents, the facility failed to ensure fall risk assessments were completed as per facility policy (Resident #31) and failed to ensure staff provided supervision to prevent a resident from leaving the facility without staff knowledge (Resident #59). The findings include: 1. Resident #31 was admitted on [DATE] with a diagnosis of dementia, diabetes, and orthostatic hypotension (a sudden drop in blood pressure when standing from a seated or lying position). A nursing quarterly evaluation dated 5/6/22 identified Resident #31 was a fall risk due to taking medications for diabetes. A fall risk assessment dated [DATE] identified Resident #31 was not at risk for falling. A Nursing quarterly evaluation dated 8/22/22 identified Resident #31 was at risk for falls due to having an unsteady gait. The Resident Care Plan dated 8/24/22 identified 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.

Based on observations, facility policy, and interviews for the only sampled resident, Resident #30, reviewed for a respiratory condition, the facility failed to properly store, label, and date a nebulizer mask. The findings include: Resident #30's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and congestive heart failure. The Resident Care Plan dated 9/18/23, identified Resident #30 had COPD. Interventions included monitoring for oral fungal infections, shortness of breath, and difficulty breathing. A Physician's order dated 9/18/23 directed to administer Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) and Budesonide Inhalation Suspension 0.5 mg/2ml (nebulizer solutions). Observation on 9/25/23 at 1:00 PM, identified that Resident #30 had a nebulizer machine on his/her bedside table with the nebulizer mask sitting on top of the machine. Additionally, the tubing was not labeled or dated. A second observation on 9/26/23 at 12:43 PM and interview with LPN #6, identified that the nebulizer mask was unlabeled and stored on top of the nebulizer…

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 Surveyor: [NAME], [NAME] Based on observation, review of the clinical record, facility policy, and interview for 2 of 7 sampled residents (Resident #23 and Resident #60) reviewed for Medication Administration, the facility failed to ensure a medication error rate of less than 5%. The findings include: 1. Resident #23 ' s diagnoses included Alzheimer's disease, depression, and anxiety. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #23 was severely cognitively impaired, required supervision for bed mobility and transfers and required setup assistance with eating. A physician's order dated 7/31/23 directed to give Norvasc 5 milligrams (mg), 2 tablets by mouth one time a day for hypertension (HTN, high blood pressure). Observation of medication preparation for Resident #23 on 9/25/23 at 10:52 AM, with LPN #1 identified that she poured 1 tablet of Norvasc 5 mg into a plastic medication cup for administration. Review of the pharmacy directions on the medication card…

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 and staff interviews, the facility failed to ensure medications were stored in sanitary conditions. The findings include: Observation of the 200 unit medication room refrigerator on 9/29/23 at 12:55 PM with the Director of Clinical Services identified a clear plastic bag with two urine specimen tubes containing urine colored substances that were dated 9/28/23. The specimen bag was placed next to a brown bag containing medications. The Director of Clinical Services indicated that specimen tubes should not be stored in the medication refrigerator and that the expectation was that staff would place specimens in the specimen refrigerator located in the soiled utility room. Subsequent to surveyor observation, the Director of Clinical Services created a sign to alert staff regarding the appropriate placement of laboratory specimens.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #28) reviewed for nutrition, the facility failed to provide appropriate adaptive dining equipment. The findings include: Resident #28's diagnoses included chronic obstructive pulmonary disease, anxiety, and vascular dementia with behavioral disturbance. The Resident Care Plan dated 8/10/23 directed to provide adaptive feeding equipment to Resident #28 as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 required set up assistance for eating. Review of the NA Resident Care Card directed staff to provide a Kennedy cup and scoop plate. A physician's order dated 8/31/23 directed to provide Resident #28 with a Kennedy cup during meals. The quarterly Nutritional assessment dated [DATE] identified that Resident #28 required adaptive feeding equipment including a Kennedy cup. Observation on 9/25/23 at 12:03 PM identified Resident #28 was noted…

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 2 of 3 sampled residents (Residents #16 & #22) reviewed for dignity, the facility failed to ensure the resident was treated in a dignified manner. 1. Resident #16's diagnoses included multiple sclerosis, immune thrombocytopenia purpura, anxiety disorder, chronic pain syndrome and osteoporosis. The quarterly MDS assessment dated [DATE] identified Resident #16 was cognitively intact, did not have behaviors, required extensive assistance for bed mobility and transfers, and utilized a wheelchair for mobility. The resident care plan dated 6/3/2021 identified Resident #16 had alteration in mood, with feelings of sadness, anxiety, and depression due to his/her need to be at the facility and his/her continuous slow decline. Care plan interventions included; acknowledge resident's mood in 1:1 interactions, encourage resident to converse and express feelings, express acceptance and provide repeated honest appraisals of resident's…

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, review of facility documentation, review of facility policy and interviews for 1 of 2 sampled residents (Resident #30) reviewed for skin conditions, the facility failed to ensure the resident's care plan interventions were implemented after a new skin injury was identified. The findings include: Resident #30's diagnoses included atrial fibrillation, heart failure, non-thrombocytopenic purpura, dementia, fibromyalgia and anxiety. The annual MDS assessment dated [DATE] identified Resident #30 was cognitively intact and required extensive assistance with all activities of daily living. The care plan dated 7/13/21 identified Resident #30 had a concern with bruising with an intervention to apply bilateral arm Geri sleeves at all times. Physician's order dated 8/1/21 directed to administer Eliquis (used to treat blood clots) 2.5 milligrams (mg) two times a day. A reportable event report dated 8/22/21 and timed 8:15 AM identified that a bruise was observed 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 reviews, observations, review of facility documentation and interviews for 1 sampled resident (Resident #42) reviewed for Activities of Daily living (ADL's), the facility failed to ensure the resident was provided the necessary assistance with shaving. The findings include: Resident #42's diagnoses included heart failure, adjustment disorder, hypertension, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #42 had moderately impaired cognition, had no behavioral symptoms, and required limited assistance with dressing and personal hygiene. The resident care plan dated 7/27/2021 identified Resident #42 required assistant to complete ADL'S with interventions that included; assist with daily bathing/grooming/dressing/mouth care and all ADL's. Observations on 8/30/2021 at 12:00 PM noted Resident #42 had visible facial hair located on the upper lip and chin area. The hair appeared to be about a quarter to half an inch long and the resident was pulling on the hair…

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.