Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Apple Rehab Middletown during CMS and state inspections, most recent first.
Failure to notify the physician/APRN when ordered meds were not given as scheduled. A resident with DM and moderate cognitive impairment missed a fingerstick, Klor-Con, Guaifenesin, and Lispro insulin; the MAR showed refused/unavailable/held codes, but the nurse's note did not document the missed care, and the APRN stated she was not notified. A covering APRN said she would have wanted notification, especially with an elevated BG and concern that Klor-Con was missed.
A facility failed to ensure timely medication administration when a charge nurse arrived late for the shift and no other nurse was assigned to start the med pass, obtain FSBS, or give insulin. Four residents had missed or delayed ordered meds and treatments, including diabetes meds, insulin, potassium, protein supplement, pain medication, and other scheduled therapies, with MAR entries showing doses as unavailable, refused, or held and incomplete nursing documentation for some omissions.
Medication administration errors were identified for several residents with diabetes, pain, and other chronic conditions. Ordered meds, including insulin, oral diabetes meds, potassium, antipsychotic therapy, protein supplement, and pain medication, were not given on time or were coded as refused, held, or unavailable. An RN stated she was late to the shift, did not notify the DNS/ADNS or supervisor, and did not search the med room or automated supply for missing meds before documenting them as unavailable.
A resident with arthritis, abnormal posture, and morbid obesity needed assistance with ADLs and transfers and wanted to get out of bed to a recliner more often because the wheelchair caused discomfort. OT documented that seating options had been exhausted, the bariatric recliner would not work with the current mechanical lift, and a new customized wheelchair would not fit through the doorway. Staff knew the lift was incompatible with the chair, but a compatible lift had not been obtained for months.
A resident with diabetes, arthritis, atrial fibrillation, and morbid obesity had physician orders on a 60-day review schedule, but the facility could not show when the orders were last signed in the paper record or EMR. The DNS and Corporate RN said orders should be signed every 30 or 60 days, but they could not provide documentation of timely physician/APRN review, signatures, or progress notes showing the orders were renewed on the required schedule.
A resident who was alert, oriented, and dependent on staff for care was subjected to inappropriate language by a nurse aide, who called the resident a "pain in the butt" during a disagreement about wheelchair equipment. This comment, witnessed by other staff and reported to social services, made the resident feel uncomfortable and disrespected, violating the requirement to treat residents with dignity and respect.
A resident with behavioral health diagnoses had a verbal altercation with a nurse aide, which was documented by an RN but not immediately reported to the DON or state agency as required. The incident was only reported the next day after administrative review, resulting in a delay in investigation and notification.
The facility failed to complete medication self-administration assessments as per policy for two residents receiving medication-assisted therapy. One resident, with opioid use and psychoactive substance abuse, did not have an updated assessment, while another, on methadone, required assistance to open medication despite being assessed as independent. Assessments were only updated after surveyor inquiry.
The facility failed to ensure medication availability and administration for a resident with liver cirrhosis, resulting in missed doses. Additionally, there were significant documentation gaps in shower provision for three residents requiring assistance, and a lack of admission body audit for a resident with existing wounds. Another resident did not receive a prescribed anti-fungal medication due to authorization issues, despite staff documenting it as administered. Lastly, the facility did not consistently monitor a resident's output as per the care plan.
The facility failed to maintain its dry food storage area free from insects, as uncovered ripe bananas in the storage room attracted fruit flies. The pest control logs had recommended covering bananas, but this was not communicated to the kitchen staff. The Dietary Director and Maintenance Director were unaware of the recommendation, leading to the infestation.
The facility failed to ensure call bells were within reach for three residents, leading to a deficiency. A resident with Parkinson's and dementia was unable to find the call bell, which was wrapped around a siderail. Another resident with polyarthritis and urge incontinence, and a third resident with severe cognitive impairment and fractures, also had call bells out of reach. The facility's policy requires call bells to be easily accessible, which was not followed.
The facility did not provide timely written responses to residents' concerns about call bells being within reach and staff response times, as noted in Resident Council meetings. From January to August 2024, these issues were not addressed until September. The Recreation Director acknowledged the existence of a form for documenting concerns but admitted it was not consistently used, with only two completed forms available and no written responses for the concerns raised during this period.
A facility failed to obtain and review advanced directives for a resident with severe dementia, resulting in a blank advanced directive form and no code status in the electronic record. Staff interviews revealed that frequent absences of MDS staff led to the oversight, and the resident was considered a Full Code by default.
A resident was prescribed Kerasal Nail Renewal for toenail fungus, but the medication was never dispensed or administered due to a lack of communication between the facility and the pharmacy. Nursing staff incorrectly signed off on the MAR, and the APRN was not informed of the issue until it was identified by a surveyor.
A resident with mild dementia was physically abused by their roommate, who has a history of aggression. The incident involved the roommate punching the resident's hands, witnessed by a Nurse Aide who intervened. Despite the facility's policy against abuse, the event occurred, highlighting a failure to protect the resident.
A facility failed to implement a comprehensive care plan for a resident with severe end-stage renal disease receiving specialized treatment. The resident's care plans did not include necessary details about the specialized treatment, fistula location, or required monitoring, as outlined in the facility's Hemodialysis Policy. Interviews revealed lapses in ensuring the care plan reflected the resident's needs.
A facility failed to revise a care plan for a resident with dementia, Covid-19, and weakness, regarding their shower preferences. Despite a physician's order for weekly body audits on shower days, progress notes did not reflect whether the resident refused or received showers. The resident's care card and plans lacked details on shower preferences and schedules, contrary to facility policies emphasizing resident rights and hygiene. The DNS confirmed the absence of documentation and adherence to the shower schedule.
A facility failed to supervise and educate staff on interventions for a resident with opioid dependence, leading to unauthorized visitor access and heroin use in the resident's room. The DNS did not ensure staff were aware of the 1:1 monitoring requirement, and a sign directing visitors to report to the nursing station was removed. The visitor log was missing, and staff were unaware of visitor restrictions.
A facility failed to document monthly weights for a resident with Type 2 diabetes and hypertension, missing weights for several months despite a care plan indicating potential nutritional decline. Interviews with staff revealed that weights were expected to be documented monthly after the initial admission period, but this was not done, potentially affecting the assessment of the resident's weight changes.
Two residents in the facility were not administered oxygen per physician's order, and their oxygen tubing was not labeled as required. One resident was using oxygen at 4 lpm without an active order, while another was observed with oxygen set at 3 lpm instead of the ordered 4 lpm, and the tubing was unlabeled. Staff interviews revealed a lack of clarity regarding the orders and labeling practices.
A resident with an egg allergy was served food containing eggs on two occasions. Despite the allergy being documented in the resident's diet slip, the dietary staff failed to adhere to the allergy information. The Dietary Manager acknowledged that the staff member responsible for plating the food had not completed the necessary in-service training on the new diet slip program.
The facility failed to submit assessment data for four residents to the state agency within the required 7-day timeframe, with delays exceeding 120 days. This occurred due to the absence of the LPN responsible for MDS coordination, during which corporate staff were supposed to assist but did not ensure timely submissions.
A resident with incontinence issues was left soaked in urine for hours due to incomplete documentation and staff shortages. The resident's care was not consistently documented across multiple shifts, violating facility policy. Staff interviews confirmed the lack of documentation, and the DNS was unaware of the incident.
Failure to Notify Physician/APRN of Missed Medications
Penalty
Summary
The facility failed to ensure the physician/APRN was notified in a timely manner when ordered medications were not administered as prescribed for three of four residents reviewed for medication errors. One resident with diabetes and depression, and with moderate cognitive impairment, had orders for fingerstick blood sugar checks four times daily, Klor-Con 10 mg three tablets daily, Guaifenesin 400 mg twice daily, and Insulin Lispro 6 units with meals. On 4/15/2026, the MAR showed the fingerstick was coded as refused, Klor-Con and Guaifenesin were coded as unavailable, and Insulin Lispro was coded as held, but the nursing note did not document that the fingerstick was not obtained or refused, or that the medications were not administered as ordered. The DNS stated she had notified the APRN that some medications were not administered, but could not provide documentation that the APRN was notified that the fingerstick, Lispro insulin, Klor-Con, and Guaifenesin were not given as ordered. The APRN who followed the resident stated she was not notified of the missed medications, and the covering APRN stated she was not notified either and would have wanted to be notified if the medications were not administered or if the resident refused. The covering APRN also stated she should have been notified because the resident's blood sugar was elevated at noon and she was concerned that the Klor-Con had been missed.
Medication Pass Delays and Missed Orders Due to Staffing Coverage Failure
Penalty
Summary
The facility failed to ensure licensed staff covered a unit to administer medications timely and failed to ensure residents were free from neglect when ordered medications, fingersticks, and treatments were not provided as scheduled. The report identified four residents reviewed for medication errors, and the facility’s abuse policy defined neglect as the failure to provide goods or services necessary for physical, mental, or psychosocial well-being. One resident with diabetes, atrial fibrillation, arthritis, and morbid obesity had orders for Jardiance, Vitamin D3, and ammonium lactate cream, but the medications scheduled for 9 AM were not signed as given at that time. The electronic MAR later showed the medications were coded as unavailable. Another resident with diabetes and depression had orders for fingersticks four times daily, Klor-Con, guaifenesin, and insulin lispro, but the 9 AM medications were not administered; the fingerstick was coded as refused, Klor-Con and guaifenesin were coded as unavailable, and insulin lispro was coded as held. The nursing note did not document that the fingerstick was not obtained or refused, or that the medications were not administered as ordered. A third resident with diabetes, dementia, and schizophrenia had orders for fingersticks, insulin lispro, aripiprazole, and liquid protein, but the electronic MAR showed the fingerstick, insulin, and liquid protein were coded as held and aripiprazole as unavailable. A fourth resident with a chronic right lower leg ulcer, cellulitis, and chronic pain had an order for Xtampza ER every 12 hours, but the 9 AM dose was not given and was coded as refused. Interviews showed the charge nurse was aware she would arrive about 9 AM instead of 7 AM, the DNS knew she was not in the building at the start of the shift, and no other nurse was assigned to start the medication pass, obtain fingersticks, or administer insulin. The charge nurse stated she did not notify the DNS or ADNS and did not ask for help to ensure medications were administered timely.
Medication Administration Errors and Unavailable Medications
Penalty
Summary
The facility failed to ensure medications were administered timely and failed to ensure staff searched for medications that were unavailable in the unit medication cart for four residents reviewed for medication errors. Resident #1 had diabetes, atrial fibrillation, arthritis, and morbid obesity, and was ordered Jardiance 25 mg daily, Vitamin D3 4000 units daily, and Ammonium Lactate cream twice daily. On 4/15/2026, the 9 AM fingerstick was 227, but the scheduled medications were not signed as given at 9 AM; later electronic MAR entries showed code 12 for unavailable medication at about 1 PM for each of the ordered medications. Resident #2 had diabetes and depression and was ordered fingersticks four times daily, Klor-Con 10 three tablets daily, Guaifenesin 400 mg twice daily, and Insulin Lispro 6 units with meals. The 9 AM medications and fingerstick were not administered as scheduled; the fingerstick was coded as refused, Klor-Con and Guaifenesin were coded as unavailable, and Insulin Lispro was coded as held with reference to nursing notes. Resident #3 had diabetes, dementia, and schizophrenia and was ordered fingersticks twice daily, Insulin Lispro 6 units with meals, Abilify 10 mg daily, and liquid protein twice daily. The electronic MAR showed the fingerstick, insulin, and liquid protein were coded as held at 12:42 PM, and Abilify was coded as unavailable. Resident #6 had a non-pressure chronic ulcer of the right lower leg, cellulitis, and chronic pain, and was ordered Xtampza ER 9 mg every 12 hours and oxycodone 5 mg every 4 hours as needed. The 9 AM Xtampza was not administered and was coded as refused. RN #1 stated she did not administer the medication, did not notify the DNS, ADNS, or nursing supervisor, and did not search the medication room or automated medication supply for missing medications because she was behind on her medication pass. RN #1 also stated she informed the next shift of medications that were not administered, and facility documentation showed she punched in at 9:06 AM after the shift had started. RN #3 stated she was unaware medications were administered late or omitted and believed the timing remained within the medication pass window.
Failure to Act on Therapy Recommendation for Alternative Lift
Penalty
Summary
The facility failed to ensure staff acted timely on therapy recommendations for alternative lifts for transfers for a resident with arthritis, abnormal posture, and morbid obesity who required assistance with ADLs. The resident’s MDS showed a BIMS score of 14 out of 15 and the care plan directed assistance with ADLs and transfers, physical and occupational therapy as ordered, and out-of-bed time on Monday, Wednesday, and Friday after breakfast with return to bed before the end of first shift. During observation and interview, the resident stated he/she was getting out of bed to a wheelchair with assistance of two aides and a mechanical lift, could only tolerate sitting in the wheelchair for limited periods because of discomfort, and wanted to get up to a recliner chair more often. Therapy documentation showed an occupational therapy screen had identified seating options and documented that prior attempts to obtain a customized wheelchair had been unsuccessful because vendors could not make a chair to the resident’s specifications. The screen also documented that the facility bariatric recliner was incompatible with the current mechanical lift because the lift would not fit around the recliner, and that a new wide customized wheelchair would not fit through the resident’s doorway. The therapist concluded that all seating options had been exhausted and that the only recommendation was to pursue potential options for alternative lifts. Interviews with therapy and corporate nursing staff showed the information had been shared with the rehab director, administrator, social worker, DNS, and nursing staff, and that the team knew the bariatric recliner could not be used with the current lift. The rehab director stated therapy had recommended a bariatric recliner but the facility’s current mechanical lift could not accommodate it, and corporate nursing staff could not explain why a mechanical lift that would work with the bariatric chair had not been obtained since the issue was identified months earlier. The facility resident rights policy directed the facility to provide quality care and services with reasonable accommodation of individual needs and preferences.
Physician Orders Not Reviewed and Renewed on Required Schedule
Penalty
Summary
The facility failed to ensure that a resident’s physician orders were reviewed and renewed at least every 60 days. Resident #1 had diagnoses including diabetes, arthritis, atrial fibrillation, and morbid obesity. The quarterly MDS showed a BIMS score of 14 out of 15, indicating no cognitive impairment, and the care plan identified diabetes, risk for hyperglycemia and hypoglycemia, and pain risk, with interventions to administer medications as ordered and assess pain. Record review identified the resident was on a 60-day schedule for review and renewal of physician orders, but the facility could not identify when the physician orders were last signed by the physician or APRN in either the paper record or the EMR. During interview, the DNS and Corporate RN stated that resident physician orders should be signed every 30 days or every 60 days, and explained that some orders were signed on paper while others were electronic in the EMR. They also stated that long-term resident orders originating before the current EMR appeared in monthly reports without physician signatures and were marked as signed in wet ink on paper. The DNS and RN were unable to provide documentation showing that Resident #1’s orders had been reviewed and signed, or any physician/APRN progress notes showing the monthly orders were reviewed and renewed. After surveyor inquiry, Corporate RN #4 provided documentation showing the monthly orders were signed by MD #1 on 4/16/2026, but could not provide documentation that the orders had been signed every 60 days before that date. The facility did not provide a policy related to physician visit frequency or the frequency of review and signatures for paper or electronic orders.
Resident Not Treated with Dignity and Respect Due to Inappropriate Staff Language
Penalty
Summary
A resident with diagnoses including atrial fibrillation, weakness, and arthritis, who was alert, oriented, and dependent on staff for personal hygiene and mobility, was not treated with dignity and respect by a nurse aide. The resident, who had a care plan addressing behaviors characterized by ineffective coping, reported that a nurse aide used inappropriate language, specifically calling the resident a "pain in the butt" during an interaction involving the placement of a wheelchair arm. This incident was witnessed by two other staff members and was later reported by the resident to the social worker, who documented that the resident felt uncomfortable due to the aide's remark. Interviews with the social worker, the nurse aide involved, and the administrator confirmed that the inappropriate comment was made and that it caused the resident to feel disrespected. The facility's Residents Rights Policy requires that residents be treated with consideration, respect, and full recognition of their dignity and individuality. The failure to uphold this policy resulted in the resident experiencing a lack of dignity and respect during the incident.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with anxiety, schizoaffective disorder, and asthma in a timely manner. The resident, who was alert, oriented, and exhibited behavioral symptoms, had a verbal altercation with a nurse aide, during which the resident yelled obscenities and racial slurs and expressed dissatisfaction with the aide's communication. The incident was documented in the nurse's note and shift report, but the Nursing Supervisor did not notify the Director of Nursing or initiate an investigation, as she was unaware that the verbal interaction could be indicative of abuse. The facility's policy required immediate reporting to the Administrator or designee and to the state agency within two hours of an abuse allegation. However, the incident was not reported to the state agency until the following day, after the Administrator and Director of Nursing reviewed the documentation. The delay in reporting and failure to initiate an immediate investigation constituted a deficiency in the facility's response to the abuse allegation.
Failure to Complete Medication Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that a medication self-administration assessment was completed according to policy for two residents receiving medication-assisted therapy. Resident #17, diagnosed with opioid use and psychoactive substance abuse, was identified as wishing to self-administer medications and was assessed as cognitively intact and independent with activities of daily living. However, the Self Administration of Medications assessment was not updated quarterly as required by the facility's policy, and it was only updated after surveyor inquiry. Resident #52, diagnosed with opioid dependence, depression, and generalized anxiety disorder, was receiving methadone and was supposed to self-administer the medication. Although the resident was assessed as independent in opening medications, an observation revealed that a nurse had to open the methadone bottle for the resident due to a functional limitation. The Self-Administration of Medications Assessment was not completed quarterly as required, and it was only completed after surveyor inquiry. The facility's policy directed that such assessments be completed on admission, quarterly, and annually.
Medication and Care Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the availability and administration of prescribed medication for Resident #6, who was diagnosed with hypertension, heart failure, and liver cirrhosis. Despite a physician's order for Rifaximin 550 MG to be administered twice daily, the medication was not available or administered on multiple occasions from 8/18/2024 to 8/29/2024. The Director of Nursing Services (DNS) could not explain the unavailability of the medication, and the pharmacy indicated that the medication was not sent due to insurance issues and a lack of authorization from the facility. Resident #6 was eventually transferred to the hospital on 8/30/2024. The facility also failed to consistently document the provision of showers for Residents #26, #27, and #52, who required assistance with activities of daily living. Despite being scheduled for weekly showers, there were significant gaps in the documentation, with no evidence of showers being provided for extended periods. The DNS was unable to explain the discrepancies between the master shower schedule and the nurse aide care cards, nor the lack of documentation for missed showers or resident refusals. Additionally, the facility did not complete a body audit for Resident #215 upon admission, despite the presence of existing wounds that required assessment and treatment orders. The nursing staff failed to document an admission nursing assessment, and subsequent weekly skin assessments did not identify or address the existing wounds. Furthermore, Resident #415 did not receive a prescribed anti-fungal medication due to a lack of authorization for dispensing, yet staff inaccurately documented the medication as administered. Lastly, the facility did not consistently monitor Resident #64's output according to the care plan, with missing records for intake and output over a specified period.
Failure to Follow Pest Control Recommendations Leads to Fruit Fly Infestation
Penalty
Summary
The facility failed to maintain its dry food storage area free from insects and did not adhere to the recommendations of their pest control program. Observations during a tour of the facility's kitchen revealed a large cardboard box in the dry storage room containing many ripe bananas, some of which were completely black in color. The box was uncovered, and numerous fruit flies were observed flying above it. The Dietary Director was unaware of how long the bananas had been there and indicated that they were not part of the menu plan and would be discarded with the next delivery. The pest control logs showed that a service report from an outside pest control company had recommended covering bananas to prevent fruit flies. However, the Dietary Director was not aware of this recommendation, as the pest control reports were reviewed by the maintenance department. The Director of Maintenance, who was responsible for reviewing these logs, was also unaware of the recommendation to cover bananas. This lack of communication and failure to follow pest control recommendations led to the presence of fruit flies in the dry storage area.
Failure to Ensure Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #20, diagnosed with Parkinson's disease, dementia, and a cognitive communication deficit, was observed sitting in a wheelchair unable to find the call bell, which was wrapped around a lowered siderail out of reach. The care plan for Resident #20 indicated a risk for falls and required staff to encourage the resident to call for assistance, highlighting the importance of having the call bell accessible. Similarly, Resident #41, with diagnoses including polyarthritis and urge incontinence, was found unable to reach the call bell, which was moved by a nursing supervisor after being informed. Resident #59, with severe cognitive impairment and fractures, also had the call bell out of reach, which was repositioned by the same nursing supervisor. The facility's policy on call bells mandates that they should be positioned for easy access by residents, which was not adhered to in these cases, resulting in the deficiency.
Failure to Address Resident Council Concerns on Call Bells
Penalty
Summary
The facility failed to ensure timely written responses to residents' concerns regarding call bells being within reach and staff response times, as expressed during Resident Council meetings. A review of the Resident Council Minutes from January 2024 through August 2024 revealed that these concerns were not addressed until the September 2024 minutes. An interview with the Recreation Director on October 7, 2024, indicated that while a form exists for documenting Resident Council concerns, it was not consistently used. The Recreation Director could only provide two completed forms and no written responses for the concerns raised from February 2024 through August 2024. The Recreation Director mentioned discussing the issues with the relevant department head, but no written documentation was available to confirm these actions.
Failure to Obtain and Review Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were obtained and reviewed in a timely manner. Resident #10, who was diagnosed with severe dementia, hypertension, and hyperlipidemia, was admitted with a moderate cognitive impairment. Despite the resident's condition, the care plan did not include any information regarding advanced directives. An observation of the clinical record revealed that the advanced directive forms were blank, and there was no indication of the resident's code status in the electronic record. Interviews with staff, including an LPN and the MDS Coordinator Nurse, revealed that the advanced directives were overlooked due to frequent absences of MDS staff, leading to a lack of routine review at care plan meetings. The facility's policy requires that advanced directives be reviewed with the resident or responsible party upon admission, but this was not adhered to, resulting in the resident being considered a Full Code by default. The oversight was acknowledged by the staff, who could not understand how the advanced directives were missed.
Failure to Administer Prescribed Medication Due to Lack of Communication
Penalty
Summary
The facility failed to notify the physician when a prescribed medication was not available for administration to a resident. The resident, who was admitted with diagnoses including sepsis, dysphagia, and generalized anxiety disorder, was prescribed Kerasal Nail Renewal External Liquid for toenail fungus. The medication was to be applied twice daily and kept in the resident's room. However, the medication was never dispensed by the pharmacy, and the nursing staff incorrectly signed off on the Medication Administration Record (MAR) as if it had been administered. Interviews revealed that the resident had requested the medication upon admission, but it was never provided. A nurse admitted to running out of the medication and planning to reorder it, while the Director of Nursing Services (DNS) confirmed that the pharmacy had not dispensed the medication due to a lack of authorization from the facility. The Advanced Practice Registered Nurse (APRN) was not informed of the issue until it was brought up by the surveyor, despite the medication being prescribed for the resident's comfort. This oversight led to a failure in communication and medication administration for the resident.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #64, who has mild dementia, anxiety, and other health conditions, was moderately cognitively impaired and required total care with bathing. On a specific date, Resident #64 was physically abused by their roommate, Resident #36, who has a history of aggression and various medical conditions, including borderline personality disorder. Resident #36 was observed punching Resident #64's hands while holding their wrist, an incident witnessed by a Nurse Aide who intervened. The facility's documentation and interviews revealed that Resident #36 believed Resident #64 was trying to trip them, leading to the aggressive behavior. Despite Resident #36's history of aggression towards staff, there was no prior history of hitting other residents. The facility's abuse policy prohibits any form of abuse or mistreatment, requiring immediate reporting and thorough investigation of any allegations. However, the incident occurred, indicating a failure to ensure Resident #64's safety from abuse.
Failure to Implement Comprehensive Care Plan for Specialized Treatment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place for a resident with severe end-stage renal disease, diabetes mellitus, and polyneuropathy, who was receiving specialized treatment. The resident was admitted with a physician's order for a renal diet and fluid restriction, and was scheduled for specialized treatment three times a week. However, the physician's orders did not specify the location of the resident's fistula or the necessary monitoring for a bruit and thrill every shift. Additionally, the admission MDS assessment did not reflect that the resident was receiving specialized treatment, and the care plans did not identify the specialized treatment, the fistula, or the required monitoring. Interviews with the Director of Nursing Services (DNS) revealed that the nurse responsible for the admission failed to ensure the baseline care plan included the resident's specialized treatment needs. The MDS nurse also did not ensure the comprehensive care plan included the specialized treatment and monitoring requirements. The facility's Hemodialysis Policy outlined the need for physician orders to include details about the specialized treatment center, frequency, and fistula care, but these were not followed. The facility was unable to provide a policy for comprehensive care plans when requested.
Failure to Revise Care Plan for Resident's Shower Preferences
Penalty
Summary
The facility failed to revise the care plan and care card for a resident with dementia, Covid-19, and weakness, regarding their shower preferences. The resident was admitted with a physician's order to perform a body audit on admission and weekly on shower day. However, progress notes from the specified period did not reflect whether the resident refused a shower or was provided a shower versus a bed bath weekly. The admission MDS assessment indicated the resident had severely impaired cognition, was occasionally incontinent, and required extensive assistance with personal hygiene, toileting, and transfers. The resident expressed that choosing between a shower, tub bath, bed bath, or sponge bath was very important, yet the care card and care plans did not specify the resident's preference or the day and shift for the shower. The facility's DNS acknowledged that the nursing assistants were expected to know the shower schedule based on the care card and a weekly shower schedule sheet at the nurse's station. If a resident did not receive their shower, the nursing assistant was to inform the charge nurse, who would then document it in the progress notes. However, there were no progress notes indicating that the resident refused showers or was given a bed bath. The DNS confirmed that the shower day and shift were not documented in the baseline care plan, comprehensive care plan, or resident care card. The facility's policies emphasized the importance of offering a full bath or shower weekly and respecting resident rights to make choices about their care, but these were not adhered to in this case.
Failure to Supervise and Educate Staff on Resident Monitoring
Penalty
Summary
The facility failed to provide necessary supervision and education regarding interventions for a resident with a history of opioid dependence, depression, and generalized anxiety disorder. The resident was on a Methadone Maintenance Program and required maximum assistance with daily activities. Despite being cognitively intact, the resident admitted to snorting heroin in their room on two occasions, facilitated by a visitor. The facility did not ensure that staff were aware of the intervention requiring all visits to be 1:1 in a common area, as indicated in the resident's care plan. The Director of Nursing Services (DNS) acknowledged that the staff were not educated about the intervention, relying instead on staff to review care plans and care cards each shift. A sign directing visitors to report to the nursing station was removed for confidentiality reasons, and there was no shift report or weekend receptionist to monitor visitor access. Additionally, the visitor log for the relevant period was missing, and staff were unaware of the visitor restrictions, leading to a failure in preventing unauthorized access to the resident's room.
Failure to Document Monthly Weights for a Resident
Penalty
Summary
The facility failed to ensure that monthly weights were completed and documented in the clinical record for a resident diagnosed with Type 2 diabetes mellitus and hypertension. The resident's care plan indicated a potential for nutritional decline following a recent hospitalization, with an intervention to weigh the resident as ordered. A physician's order directed weekly weights for four weeks, but there were no follow-up orders noted. The review identified missing weights for January, February, May, June, and August 2024. Interviews with facility staff, including an RN and a dietician, revealed that the facility's expectation was for weights to be performed and documented monthly after the initial admission period. The RN confirmed that weights were missing for several months and that nursing assistants were responsible for obtaining weights, while nursing staff were responsible for documentation. The dietician noted that missing weights could affect the assessment of weight loss or gain, and confirmed that the resident was not deemed at nutritional risk, thus requiring monthly weights. The facility's weight monitoring policy also indicated that weights should be taken monthly unless otherwise specified by a physician or dietician.
Failure to Administer Oxygen Per Physician's Order and Label Tubing
Penalty
Summary
The facility failed to administer oxygen per physician's order and label the oxygen tubing for two residents. Resident #40, who has diagnoses including diabetes mellitus, hypertension, and muscle weakness, was observed using oxygen at 4.0 liters per minute (lpm) via a nasal cannula without an active physician's order. Despite being dependent on staff for personal hygiene and requiring maximum assistance for bed mobility, there was no documentation of an active oxygen order, only a discontinued order to titrate oxygen below 92% from March 2024. Interviews with the LPN and DNS revealed that Resident #40 had been using oxygen at 4.0 lpm for several weeks without a current physician's order, and the DNS confirmed that any charge nurse could initiate an order with physician approval. Resident #366, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), dysphagia, and hypothyroidism, was observed with oxygen set at 3 liters per minute instead of the ordered 4 liters per minute. Additionally, the oxygen tubing was not labeled as per facility practice. The physician's order dated 9/10/24 directed continuous oxygen at 4 lpm, but observations on 9/30/24 and 10/01/24 showed discrepancies in the oxygen administration. An LPN was unsure why the oxygen was set at 3 liters and why the tubing was not labeled, although the facility's policy requires a physician's order for oxygen administration.
Failure to Prevent Serving Allergenic Food to Resident
Penalty
Summary
The facility failed to ensure that a resident with a known egg allergy was not served food containing eggs. Resident #215, who was admitted with diagnoses including cellulitis, dysphagia, and anxiety, had an allergy to eggs documented in their admission nursing assessment and diet slip. Despite this, the resident was served French toast, which contains eggs, at breakfast. After the resident informed the server of their allergy, plain toast was provided instead. The Dietary Manager acknowledged that the diet slip indicating the egg allergy was not updated until after breakfast, and there was no diet slip available for the resident at that time. On a subsequent occasion, scrambled eggs were plated for the same resident, despite the diet slip prominently displaying the egg allergy in red ink. The server, Dietary Aide #1, noticed the allergy on the slip and removed the plate before it was served. The Dietary Manager admitted that [NAME] #1, who plated the eggs, had not completed the required in-service training on the new diet slip program. The Dietary Manager had no explanation for allowing [NAME] #1 to serve residents without completing the training.
Delayed Submission of Resident Assessments
Penalty
Summary
The facility failed to submit the assessment data of four residents to the state agency within the required timeframe of 7 days. The assessments for these residents were delayed for over 120 days. This deficiency was identified during a review of the residents' assessments and staff interviews. The delay occurred because the LPN responsible for coordinating the Minimum Data Set (MDS) assessments was on leave during several months, including July, September, October through December, and again in February. During her absence, corporate staff were supposed to assist with completing and submitting the MDS assessments, but the submissions were not made timely.
Incomplete Documentation of Bladder and Bowel Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with bladder and bowel incontinence. The resident, who was admitted with diagnoses including muscle weakness, hemiplegia, and anxiety disorder, reported being left soaked in urine for several hours without assistance. The resident also mentioned that the call bell was out of reach, and when a staff member entered the room, they were advised to use the call bell, which was not possible. The clinical record review revealed missing documentation of bladder and bowel care on multiple shifts, including the day the resident reported the incident. Interviews with staff, including a nurse aide and registered nurses, confirmed that documentation of care was not consistently completed by the end of each shift, as required by facility policy. The nurse aide assigned to the resident on the day of the incident admitted to providing care but did not document it due to staff shortages. The charge nurse and the Director of Nursing Services were unaware of the incident and could not explain the lack of documentation. The facility's policy mandates that documentation should be completed as soon as possible after care is provided, ideally within the same shift, and any late entries should be clearly identified.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Water's Edge Center For Health & Rehab | 1.3 mi | ★★★★★ | 15 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 1.6 mi | ★★★★★ | 13 | 0 |
| Portland Care & Rehab Centre, Inc | 3.1 mi | ★★★★★ | 19 | 0 |
| Pilgrim Manor | 4.4 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Cromwell | 4.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.