Essex Rehabilitation and Healthcare Center

Based on record review, interview, and facility document and policy review, the facility failed to ensure the residents' right to be free from misappropriation of property was maintained for 3 of 3 residents reviewed for misappropriation of resident property (Resident (R)45, R10, and R158). The findings include: Review of the facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property, revised 10/15/2022, from the Administrative Policies manual, revealed the facility believed its residents had the right to be free from .or misappropriation of resident property. Per review, the facility would do whatever was in its control to prevent .or misappropriation of their property. Review of the facility policy titled, Abuse, Neglect, Misappropriation, and Exploitation, dated 08/2019, from the Social Services Manual revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Continued review revealed examples 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 interview, record review, and facility document and policy review, the facility failed to ensure it did not employ staff having been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, which affected 3 of 3 residents reviewed for misappropriation of resident property (Residents (Rs)45, R158, and R10), and had the potential to affect all residents that resided in the facility. The facility employed State Registered Nurse Aide (SRNA) 36, whose preemployment background check reflected a guilty finding for theft-receipt of stolen credit/debit card. In 01/2025, the facility, in conjunction with the local police department, identified SRNA 36 as the suspect in the misappropriation of Residents (Rs) 45's, 158's, and 10's resident funds. Subsequently charges were filed in Kentucky and Indiana, and a warrant issued for SRNA 36's arrest. The findings include: Review of the facility policy, Abuse, Neglect, or Misappropriation of Resident Property, revised…

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 interview, record review, and facility document and policy review, the facility failed to ensure a thorough investigation was completed and submitted to the State Survey Agency (SSA) within five days of forming the suspicion a resident's financial information was being used fraudulently for 3 of 3 residents sampled for misappropriation of resident property (Residents (R)45, 158, and 10). On 01/09/2025, R45 reported suspicious charges on his/her financial statement to facility staff. However, the facility failed to submit an initial report of suspected misappropriation of resident property to the SSA or conduct interviews with residents to determine if other residents were potentially impacted, or interview staff to determine what knowledge they might have had until 01/20/2025. On that date a second resident's family (R158's) contacted the Administrator about what appeared to be fraudulent transactions on their family member's financial account. Additionally, on 01/30/2025, a third resident (R10) reported to the Administrator he/she identified fraudulent charges on his/her…

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

Based on observation, interview, record review, facility document and policy review, the facility failed to provide care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 2 residents sampled for skin conditions out of the total sample of 32, (Resident (R)95). R95 sustained a skin tear; however, staff failed to notify the physician and obtain an order for treatment and failed to complete an incident report and/or skin assessment. Staff then provided treatment to the skin tear without an order. The findings include: Review of the facility's Wound Care Manual of the policy titled, Skin Tear Dressing Procedure, version dated 05/22/2018, revealed to obtain a Physician's order and May Follow Facility Skin and Wound Protocol'. Per review, the Wound Protocol noted to cleanse a wound with normal saline or appropriate wound cleanser; if a skin flap remained to gently approximate skin edges and apply steri strips; apply a transparent dressing; and change the transparent dressing prn [as needed] or when wound…

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, interview, record review, and facility policy review, the facility failed to provide an assistive device in a manner designed to prevent accidents for 1 of 4 sampled residents (Resident (R) 28). Staff failed to follow instructions for the use of a mechanical lift while providing care for R28. The findings include: Review of the facility document Active Stand Up Lifting, of the policy titled, Mechanical Lift, dated 04/2013, revealed, active stand-up lifting with [NAME] and Liko Safety Vest, (product designed to help with patient support and stability) revealed instructions for use of the stand-up lift, including directions to, Position [NAME] and adjust the width of the base, so that the patient's feet can be centered on the footrest. Further review revealed, Attach and tighten the strap around the lower legs. Review of the admission Record for R28 revealed the facility admitted the resident on 06/19/2023, with diagnoses that included hemiplegia and hemiparesis (partial weakness on one side…

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, interview, record review, facility document review, and facility policy review, the facility failed to take action to ensure nutritional parameters were maintained for one (Resident (R) 48) of two residents reviewed for nutrition. R48, who was clinically underweight, based on a low Body Mass Index (BMI), had orders for a nutritional supplement. The Registered Dietitian (RD) and medical provider were not promptly informed when the resident was not offered and/or did not consume the full amount of ordered supplement. The findings include: Review of the facility policy titled, Weight Policy, dated 08/2013, revealed, The weight committee/care plan team will review and take appropriate measures to resolve weight loss or gain. Review of the admission Record for R48 revealed the facility admitted the resident on 07/30/2021, with diagnoses of adult failure to thrive and other symptoms and signs concerning food and fluid intake. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/21/2025, revealed R48 had a Brief…

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 interview, record review, and facility document and policy review, the facility failed to report suspected misappropriation of resident property to the State Survey Agency (SSA) within 24 hours of forming suspicion of misappropriation for 1 of 3 residents reviewed for misappropriation of resident property (Resident (R)45). The findings include: Review of the facility's, Administrative Policies manual area titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 10/15/2022, revealed the Administrator was to ensure the Division of Licensure and Regulation (Office of Inspector General (OIG) and Adult Protective Services [APS] were notified immediately but no later than two hours after an allegation was received for all complaints of abuse .or misappropriation of resident property. Continued review revealed for all allegations that did not involve abuse or had not resulted in serious bodily injury, the Administrator was to ensure the Division of Licensure and Regulation and APS and other appropriate agencies were notified no later than 24 hours after 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.

Based on observation, interview and review of facility policy it was determined the facility failed to store food under sanitary conditions. Observations on initial kitchen tour revealed opened containers of spices not dated; a box of cornstarch box missing the top and not dated; and a white powdery substance in a clear container with a scoop and not labeled or dated. In addition, observations of resident nursing unit nourishment refrigerator revealed resident food products not labeled or dated. The findings include: 1. Review of the facility policy Food Storage, dated 11/15/12, revealed staff labeled all incoming foods with a delivery date and/or open date or use by date. Review of the facility policy Food Safety Policy, dated 06/23/17, revealed the goal of the nursing facility ensured the safety of all residents and included the prevention of food borne illnesses. Residents had the right to receive foods brought in by family and visitors, and staff placed all foods in sealed storage containers and dated for the date the food arrived at the facility. Additionally, foods brought…

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, interview, and facility policy review, it was determined the facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 for one (1) of two (2) medication storage refrigerators. The South Unit medication refrigerator contained four (4) vials of Ativan, (a Schedule IV medication classification, and a benzodiazepine with antianxiety, sedative, and anticonvulsant effects), which were not stored or secured properly. The findings include: Review of the facility policy Controlled Substances, dated 10/01/15 revealed under General Provisions 1 that controlled substances were classified by the Controlled Substances Act of 1970 as follows D. Schedule IV drugs with less potential for abuse and included benzodiazepines, and all controlled substances were to be stored separately from other medications and under double lock at all times. The policy did not reveal Schedule IV drugs, which required refrigeration, be stored and…

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

Based on record review, interview, and facility policy review it was determined the facility failed to develop an baseline care plan for anticoagulation therapy within forty-eight (48) hours for one (1) of twenty-six (26) sampled residents, Resident #62. The findings include: Review of the facility's policy Resident Care Plan, page revision dated 11/13/17, revealed the initiation of the baseline care plan began with the designated registered nurse (RN) upon admission of a resident. The baseline care plan included the instructions needed to provide effective and patient-centered care for the resident to meet professional standards of quality care. The baseline care plans included, but were not limited to the initial goals of a resident, physician orders, dietary orders, therapy services, social services, and PASRR recommendations, if applicable. Staff completed the baseline care plan within forty-eight (48) hours of the residents' admission to the facility. Review of the clinical record for Resident #62 revealed the facility admitted the resident on 10/11/18 with diagnoses including…

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.