Apple Rehab Rocky Hill

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 2 residents (Resident #11) reviewed for abuse, the facility failed to protect Resident #11 from abuse by Resident #31, who stabbed Resident #11 in the neck with a fork. The findings include: a. Resident #11 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety disorder, and difficulty walking. The admission MDS dated [DATE] identified Resident #11 had severely impaired cognition, required assistance to stand and transfer, and used a wheelchair or walker for mobility. b. Resident #31 had diagnoses that included major depressive disorder, post-traumatic stress syndrome (PTSD), and mild cognitive impairment with memory loss. Resident #31's annual MDS dated [DATE] identified the resident had intact cognition and was independent with all aspect of activities of daily living. Resident #31 was sent to the hospital on 5/6/24 due to disorientation and a decreased level 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 1 of 2 residents (Resident #11) reviewed for abuse, the facility failed to immediately report to the State Survey Agency, witnessed abuse by Resident #31, who stabbed Resident #11 in the neck with a fork, and failed to report the results of the investigation, in accordance with State law, to the State Survey Agency, within 5 working days. The findings include: a. Resident #11 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety disorder, and difficulty walking. The admission MDS dated [DATE] identified Resident #11 had severely impaired cognition, required assistance to stand and transfer, and used a wheelchair or walker for mobility. b. Resident #31 had diagnoses that included major depressive disorder, post-traumatic stress syndrome (PTSD), and mild cognitive impairment with memory loss. Resident #31's annual MDS dated [DATE] identified the resident had intact cognition…

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, and interviews for 1 of 5 residents (Resident #2) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to complete a rescreen PASARR following a new serious mental disorder diagnoses that was identified on 1/13/22. The findings included: Resident #2 was admitted to the facility in August 2019 with diagnoses that included delusional disorder, paranoid personality, and anxiety disorder. A PASARR level 1 screening dated 8/15/19 identified that Resident #2 had a diagnoses of anxiety disorder and noted the utilization of Seroquel (antipsychotic medication) for treatment. Based on information that was received, a Level II evaluation is not required at this time and this Level I was approved with a Level I negative outcome. Should there be an exacerbation related to the mental illness, a status change should be submitted to Ascend for further evaluation. A Connecticut Long Term Care (LTC) Level of Care Determination Form with a review date of 11/11/19 identified admitting diagnoses hypertensive…

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 7 residents (Resident #19 and 26) reviewed for falls, the facility failed to ensure that an RN assessment was completed after an unwitnessed fall, and failed ensure post-accident and incident (A&I) assessments and neurological assessments were initiated and completed per facility policy following unwitnessed falls and for 1 of 4 residents (Resident #65) reviewed for medication administration, the facility failed to ensure a medication was administered per the physician's order. The findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses that included dementia, weakness, and cardiomegaly. The quarterly MDS dated [DATE] identified Resident #19 had severely impaired cognition, was frequently incontinent of bowel, occasionally incontinent of bladder and required partial assistance from staff with dressing and maximal assistance with toileting and bathing. The MDS also identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interviews for 3 of 5 residents (Resident #11, 18 and 39) reviewed for respiratory care, the facility failed ensure respiratory equipment was maintained and stored in a clean and sanitary manner and respiratory equipment was changed according to physician orders. The findings include: 1. Resident #11 had diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure and history of hypoxemia (low oxygen level). The quarterly MDS dated [DATE] identified Resident #11 was cognitively intact, required limited one person assist with bed mobility and transfers, independent with eating. The care plan dated 7/3/24 identified Resident #11 was at risk for respiratory distress related to COPD. Interventions included to notify the physician for congestion wheeze, shortness of breath and provide oxygen/medications as ordered. Physician orders dated 9/1/24 directed to administer oxygen at 3 liters per minute for oxygen saturation less 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policies, and interviews for the only sampled resident (Resident #14) reviewed for a specialized medical treatment, the facility failed to maintain an accurate daily fluid intake record for a resident on a fluid restriction. The findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on a specialized medical treatment, diastolic (congestive) heart failure, and chronic constrictive pericarditis. Physician's orders for September 2024 (original date 10/19/21) directed a fluid restriction: 1000ml in 24 hours. The annual MDS dated [DATE] identified Resident #14 had intact cognition, was on a therapeutic diet, and had received dialysis within the last 14 days. The care plan dated 9/19/24 identified Resident #14 was at risk for impaired nutrition, inadequate energy/fluid intakes, fluid overload, and weight fluctuations in the setting of chronic illness…

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 records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #3) reviewed for medication administration, the facility failed to notify family/responsible party of a medication change. The findings included: Resident #3 diagnoses included dementia, encephalopathy, and an adjustment disorder. Review of the Resident Care Plan dated 12/7/22 identified staff assistance with activities of daily living, risk for sensory-perceptual alterations and complications such as: impaired mobility, muscle atrophy, depression, and anxiety, and fall risk due to multiple risk factors with interventions directed fall prevention including administering medications as ordered. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 as severely cognitively impaired and required substantial assistance with activities of daily living. A physician's order dated 1/26/24 directed Seroquel 25 milligrams, one table by mouth for seven (7) days for anxiety.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, interviews, facility documentation and policies for one (1) of three (3) residents (Resident #3) reviewed for abuse and accidents the facility failed to complete investigations in accordance with facility policy. The findings included: Resident #3 diagnoses included dementia, encephalopathy, adjustment disorder and difficulty in walking. The annual Minimum Data Set assessment dated [DATE] identified Resident #3 as severely cognitively impaired and required substantial assistance with oral, toileting and personal hygiene and moderate assistance with walking. A physician's order dated 1/13/23 directed to transfer/ambulate with assist of one with rolling walker. Review of the Resident Care Plan dated 2/23/23 identified staff assistance with activities of daily living, risk for sensory-perceptual alterations and complications such as: impaired mobility, muscle atrophy, depression, and anxiety, and fall risk due to multiple risk factors with interventions that directed fall…

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 two (2) residents, (Resident #2), reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with physician's orders. The findings include: Resident #2 was admitted to the facility with diagnoses that included psychoactive substance induced mood disorder, anxiety and bipolar disorder. The care plan dated 4/8/24 identified Resident #2 was sad and depressed with interventions that included to provide medication as the physician orders. The care plan further identified Resident #2 was at risk for potential adverse effects of psychotropic drug use with interventions that included to consult with psychiatric services as needed and that Resident #2's mood/behaviors may fluctuate due to diagnosis. The admission MDS dated [DATE] identified Resident #2 had no impairments in cognition, had no indicators of psychosis and no behavioral symptoms and required…

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, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #8) were reviewed for pain management, the facility failed to ensure Resident #8 received the scheduled and as needed pain medications within the facility time parameters for medication administration. The findings include: Resident #8's diagnoses included malignant neoplasm of the bone, secondary malignant neoplasm of liver and intrahepatic bile duct, and adult failure to thrive. The Resident Care Plan dated 8/30/23 identified at risk for pain and discomfort and opioid medication to help manage moderate to severe pain. Interventions directed to administer medications as ordered by the physician, activity as tolerated, assist to turn and reposition per policy and as needed for comfort, determine level of pain using pain scale, either verbal or non-verbal, before administering as needed medications, watch for changes in metal status and report to 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 one (1) of three (3) residents, (Resident #1), reviewed for diabetes management, the facility failed to notify the physician and the responsible party when the resident's blood sugar was noted to be abnormal. The findings include: Resident #1 had diagnoses that included type 1 diabetes mellitus, end stage renal disease, and hypertension. The nursing admission assessment dated [DATE] identified Resident #1 had intact cognition, was always frequently incontinent of bowel and bladder and was dependent with activities of daily living. The care plan dated 12/28/2023 identified Resident #1 was at risk for hyperglycemia and hypoglycemia with interventions that directed to watch for any acute signs/symptoms of hypoglycemia such as vagueness, dizziness, weakness, pallor, tachycardia, diaphoresis, seizures and coma and report to MD/APRN. A physician's order dated 12/28/2023 directed to obtain Resident #1's blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for abuse, the facility failed to ensure residents were free from verbal abuse. The findings include: Resident #2 had diagnoses that included major depressive disorder with severe psychotic symptoms, anxiety, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #2 had intact cognition, was continent of bowel and bladder and required supervision with transfers, personal hygiene, toileting, upper body dressing and was independent with bed mobility. The care plan dated 3/19/2024 identified Resident #2 can have increased agitation at times with no apparent reason related to psychiatric illness with interventions that directed to offer to discuss options for appropriate channeling of anger. Review of the Emergency Medical Services (EMS) run sheet dated 3/19/2024 at 9:53 P.M. identified Resident #2 called 911 and staff were unaware 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 one (1) of three (3) residents,(Resident #1), reviewed for diabetes management, the facility failed to ensure a resident with diabetes had an order in place to treat hypoglycemia, and failed to ensure a resident's blood sugar was rechecked after providing treatment for hypoglycemia. The findings include: Resident #1 had diagnoses that included type 1 diabetes mellitus, end stage renal disease, and hypertension. The Nursing admission assessment dated [DATE] identified Resident #1 had intact cognition, was always frequently incontinent of bowel and bladder and was dependent with Activities of Daily Living. The care plan dated 12/28/2023 identified Resident #1 was at risk for hyperglycemia and hypoglycemia with interventions that directed to watch for any acute signs/symptoms of hypoglycemia vagueness, dizziness, weakness, pallor, tachycardia, diaphoresis, seizures and coma and report to MD/APRN. A physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for accidents, the facility failed to ensure a that a resident was not left unsupervised outside the facility at night while the facility doors were locked. The findings include: Resident #2 had diagnoses that included major depressive disorder with severe psychotic symptoms, anxiety, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #2 had intact cognition, was continent of bowel and bladder and required supervision with transfers, personal hygiene, toileting, upper body dressing, and was independent with bed mobility. The care plan dated 3/19/2024 identified Resident #2 can have increased agitation at times with no apparent reason related to psychiatric illness with interventions that directed to offer to discuss my options for appropriate channeling of anger. A nurse's note dated 3/19/2024 at 10:41 P.M. written by RN #2…

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 dialysis, the facility failed to provide a meal to a resident who was leaving the facility prior to the morning meal for dialysis treatment. The findings include: Resident # 1's had diagnoses that included end stage renal disease, type 1 diabetes mellitus and hypertension. The Nursing admission assessment dated [DATE] identified Resident #1 had intact cognition, was always frequently incontinent of bowel and bladder and was dependent with Activities of Daily Living. The care plan dated 12/28/2023 identified Resident #1 had chronic renal disease and goes to hemodialysis 3 times weekly with interventions that direct to provide Resident #1 with his/her diet as ordered and coordinate nutritional care with the registered dietician. Interview with the DNS on 4/16/2024 at 10:45 A.M. identified on 12/30/2023 Resident #1 was not served an early breakfast 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, facility policy and interviews for three of four sampled residents (Residents #1, #2, #3, and #4) who were reviewed for an allegation of abuse, the facility failed to ensure Residents #2, #3 and #4 were free from physical abuse by Resident #1. The findings include: 1. Resident #1's diagnoses included cerebral cysts, mood disorder, traumatic brain injury (TBI), adjustment disorder with anxiety and depression, seizures, hydrocephalus, and post-traumatic stress disorder (PTSD). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition, was independent with bed mobility and required supervision for transfers. The Resident Care Plan dated 3/24/23 identified Resident #1 was impulsive, not always able to control his/her behavior, and directed anger towards others. Interventions directed to encourage resident to call a staff member for assistance when another resident directs his or her anger toward Resident #1, if…

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 policy, and interviews for 30 of 34 residents (Residents #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, and #34) reviewed for comprehensive assessments, the facility failed to complete Minimum Data Set (MDS) assessments within the regulatory time frame. The findings include: Review of Minimum Data Set (MDS) assessments identified the following: Resident #5 had a quarterly MDS dated [DATE] with the status of in process. Resident #6 had a quarterly MDS dated [DATE] with the status of in process. Resident #7 had an admission MDS dated [DATE] with the status of in process. Resident #8 had a quarterly MDS dated [DATE] with the status of in process. Resident #9 had a quarterly MDS dated [DATE] with the status of in process. Resident #10 had a quarterly MDS dated [DATE] with the status of in process. Resident #11 had an admission MDS dated [DATE] with the status…

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 interview the facility failed to have adequate policies and procedures in place to address continuity of care in an internet service outage/disruption, including medication administration for 16 of 61 residents (Residents #1, 5, 6, 7, 12, 18, 19, 22, 30, 32, 35, 38, 41, 46, 50 and 160) who required medications during an internet service outage/distruption. The findings include: Interview with LPN #2 on 4/28/22 at 7:10 AM identified she was unable to access the electronic MAR to pass medications and thought the program was down. LPN #2 indicated if she couldn ' t access the electronic medical record, including the MAR, she would need to go to each individual paper medical record and verify after review of the physician's orders, the required medications for each resident for the morning medication pass. LPN #2 indicated that the facility would provide a paper MAR for her to document the medication administration. Interview with Administrator on 4/28/22 at 7:20 AM identified that the facility internet…

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 interview for 1 resident (Resident #26) who required a CPAP (A CPAP is a continuous positive airway pressure machine used as a common treatment for sleep apnea), the facility failed to ensure that CPAP was stored in accordance with facility policy and infection control. The findings included: Resident #26's diagnoses included anxiety disorder, obstructive sleep apnea, and obesity. A quarterly MDS dated [DATE] identified Resident #26 had intact cognition and required assistance with care. Observation on 4/26/22 at 10:20 AM identified the face-side of the resident's CPAP mask was resting on the bedside table, opened to air and the environment, without the benefit of being covered. Interview and review of the CPAP policy with RN #1 on 4/27/22 at 10:03 AM identified it is facility policy that when the CPAP mask is not in use it should be cleaned, allowed to dry and then placed in a respiratory bag for storage.

Based on observations, review of medication storage, review of facility documentation and interviews for one of two medication rooms (ambrosia/empire) the facility failed to ensure medications were stored safely in the medication refrigerator. The findings include: Review of the Ambrosia/Empire medication storage area on 10/25/21 with Licensed Practical Nurse (LPN #2) at 11:00 AM identified that the refrigerator temperature log lacked documentation of daily checks for August 2021 on 24 occasions from October 1, 2021, to October 24, 2021, the refrigerator temperature log lacked documentation of 21 daily checks. There were 9 unopened insulin pens and 8 dietary supplements stored in the refrigerator. Interview with LPN #2 on 10/25/21 at 11:05 AM identified that she was per diem staff and although she knew the medication refrigerator should be checked, she was unsure of the frequency and on what shift. She identified that the current temperature in the Ambrosia /Empire medication refrigerator was 40 degrees Fahrenheit. Interview with RN #2 on 10/25/21 at 11:15 AM identified that she 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 review of facility documentation, review of facility policy and staff interviews for a review of the facility infection control, the facility failed to conduct a thorough outbreak investigation including contact tracing and to report to outbreak to the state agency when an employee tested positive for COVID-19. The findings included: Review of the employee line list identified NA #1 tested positive for COVID-19 on 10/12/2021. Review of the FLIS Reportable Event website identified the outbreak was not reported. Interview with the Administrator on 10/21/2021 at 12:15 P.M. identified he did not conduct contact tracing when NA #1 tested positive for COVID -19, however because she worked a partial 7-3 PM shift on 10/12/2021 he had all staff who worked that day tested and tested all residents Additionally, he did not determine if there was any exposure to employees who worked with NA #1 on 10/11/021 because he did not realize that was required. Further, the Administrator identified he did not have an Assistant Director of Nursing (ADNS), DNS and an Infection Control Nurse and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, facility policy and staff interviews for six employees (NA #2, NA #8, LPN#1, LPN #5, Housekeeper #1, and [NAME] Supervisor #1), the facility failed to ensure COVID-19 testing were conducted in accordance with CDC guidance for the employees. The findings included: Review of the Employee line list identified NA #1 tested positive for COVID -19 on 10/12/21. Review of the nursing schedule dated 10/11/2021 and 10/12/2021 identified NA #1 worked on the 7-3 P.M. shift on the [NAME] Unit. a.Review of the staff testing logs identified facility staff were rapid antigen tested immediately on 10/12/21 through 10/19/2021 and tested on ly once. However, LPN #1, and NA #2 who worked with NA #1 on 10/11/2021 were not tested at all. Further, LPN #1 and NA #2 worked on the same unit with NA #1 on 10/11/2021, the day she tested positive returned to work on 10/14/2021 without the benefit of COVID-19 testing. Although requested, the facility failed to provide documentation of contact…

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, facility policy and interviews for one of two residents reviewed for abuse (Resident #12), the facility failed to treat Resident #12 with respect and dignity when providing care. The findings include: Resident #12 was admitted to the facility with diagnoses that included a right below the knee amputation, congestive heart failure, iron deficiency anemia and diabetes mellitus. A Resident Care Plan (RCP) dated 7/9/21 identified that Resident #12 had anemia and became fatigued quickly with interventions to offer reminders to pace him/herself and to take time with tasks. Additionally, Resident #12 had cardiovascular disease with interventions that included to encourage short periods of activity, activities as tolerated and pace to conserve energy. The resident required assistance with Activities of Daily Living (ADL) with interventions that included assist as needed to meet toileting needs. A 5-day Minimum Data Set (MDS) 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 observations, review of the clinical record, review of facility policy and staff interviews for one of four sampled residents (Resident #20) reviewed for ADL, the facility failed to ensure a resident was walked according to the functional maintenance program. The findings included: Resident #20 was admitted with diagnoses that included major depression, lymphocytic leukemia, anxiety, and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, extensive assistance of one person for transfers, assist of one person for walking in the hallway and used a walker. The Resident Care Plan (RCP) dated 8/24/2021 identified a problem with mobility and interventions included a functional maintenance program and directed to ambulate 75-100 feet with a rolling walker and refer to current activity orders for mobility. The physicians' orders dated 10/5/2021 directed to ambulate with the assistance of one person with a rolling walker. The ambulation documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and staff interviews for one of five sampled residents (Resident #20) reviewed for unnecessary medications, the facility failed to ensure orthostatic blood pressures were monitored weekly with in accordance with facility practice. The findings included: Resident #20 was admitted with diagnoses that included major depression, lymphocytic leukemia, anxiety, and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, extensive assistance of one person for transfers, assist of one person for walking in the hallway and used a walker. The physician's order dated 8/20/21 directed to administer Abilify (Anti-psychotic) 2 Milligram (MG) by mouth daily to check orthostatic blood pressures every week on Tuesday. The Resident Care Plan (RCP) dated 8/24/2021 identified a problem with risk for potential adverse effects of psychotropic drug use antipsychotic medication for obsessive compulsive 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 review of the clinical record, review of facility policy and staff interviews for one sampled resident (Resident # 55) reviewed for death, the facility failed to ensure meals, intake and output, vital signs and clinical assessments were consistently documented in the medical record. The findings included: Resident #55 was admitted with diagnoses of anorexia nervosa, anxiety, depression, and schizoaffective disorder and sacral fracture. The admission MDS assessment dated [DATE] identified severe cognitive impairment, and Resident #55 required extensive assistance of one staff to transfer, dress, use the bathroom and required supervision to eat. The Resident Care Plan (RCP) dated 8/18/21 identified a problem of at risk for inadequate intake related to anorexia, impaired swallowing, and severe malnutrition and interventions included to provide diet as tolerated, intake and output monitoring per policy and to offer snacks per nutritional approached as recommended by the dietician. a.Review of the fluid…

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 documentation of the facility infection control program and staff interviews, the facility failed to designate a qualified infection preventionist who was responsible for managing and overseeing the facility's infection control program. The findings include: Interview with the Administrator on 10/21/2021 at 10:30 A.M. identified the facility did not have an Infection Control Nurse and had received a Consent Order from the state on 10/19/2021 that directed the facility to hire an Infection Preventionist within 30 days. Additionally, the Infection Control Nurse RN#5 resigned her position on August 12, 2021 and remained in the facility part time on the 3-11 PM shift and worked as charge nurse or supervisor. The Administrator further indicated the DNS covered the Infection Control position. The DNS resigned on 10/2/2021 and the Administer identified he did not appoint an Infection Control Preventionist designee because he did not have anyone in the facility who could help consistently secondary to no DNS or ADNS and he had recently offered the position to two…

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.