Below 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 Rocky Hill during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment, who was not identified as an elopement risk, left the facility unnoticed and was found by police over two hours later in a snowbank, confused and with signs of cold exposure. Staff did not monitor the resident's whereabouts or meal intake, and there was a lack of communication between staff regarding the resident's location. The facility could not provide a policy on routine safety monitoring, and documentation of ADL tasks was lacking for the shift.
A resident with multiple serious diagnoses was denied admission after arrival due to lack of notification and documentation, and the Medical Director was not informed of the situation. In a separate case, another resident missed 24 doses of prescribed pregabalin for chronic pain, with no provider notification or documentation of the omissions, despite facility policy requiring such communication.
A resident with chronic and neuropathic pain missed 24 doses of pregabalin over six weeks due to a prescription error and subsequent supply issues. The provider's order for pregabalin three times daily was not followed after a prescription was sent to the pharmacy with incorrect instructions, leading to limited supply and denied refills. The pharmacy did not question the unusual order, and no alternative medication was provided when pregabalin was unavailable. Facility policy requiring immediate provider notification and documentation was not followed.
A resident with multiple acute medical conditions was transferred from a hospital for skilled nursing care, but due to a breakdown in the admissions process—including lack of notification, missing documentation, and failure to communicate with the hospital or admissions staff—the resident was not admitted and left the facility without receiving intended care. Key staff were unaware of the pending admission, and the medical director was not informed of the issue until after the resident's departure.
A resident with dementia and a history of falls, who required one-person assistance and a rolling walker for ambulation, was left unsupervised while walking without an assistive device. Staff failed to maintain visual supervision as one nurse aide left to retrieve the resident's wheelchair and another staff member returned to her office. During this lapse in supervision, the resident fell, resulting in a right humerus fracture and a laceration to the eyebrow.
A resident with multiple medical conditions experienced a fall resulting in a fracture and was discharged from the ED with instructions for orthopedic follow-up within one week. The facility failed to arrange this follow-up in a timely manner, resulting in a delay of over two months before the resident was seen by orthopedics. Documentation and staff interviews confirmed that the process for arranging the appointment was overlooked, and no evidence of timely contact with the orthopedic office was found.
A resident with significant mobility needs developed a stage 2 pressure ulcer after staff failed to inspect the skin under a soft cast for over two months, despite facility policy requiring regular skin checks. Documentation and interviews confirmed that no orders or assessments for skin integrity beneath the splint were completed, resulting in the ulcer being discovered only when the splint was removed.
The facility failed to maintain a clean, safe, and homelike environment, with observations of dirt, debris, and damage in resident rooms and common areas. Infection control documentation lacked specificity, and staff interviews confirmed awareness of these issues. On the Ambrosia Unit, cable TV wiring obstructed views, with plans to resolve this with a new provider. Policies and job descriptions were not provided.
A facility failed to keep an emergency exit clear, with equipment blocking access, and did not complete timely fall risk assessments for a resident with multiple falls. Despite initial corrective actions, the exit was repeatedly obstructed by carts, wheelchairs, and lifts. Additionally, a resident with a history of falls and injuries did not receive consistent fall risk assessments as required by the facility's policy.
The facility failed to ensure staff understood the protocol for Enhanced Barrier Precautions (EBP), as five rooms with residents on EBP lacked visible signage. Instead, orange stickers were used, but staff interviews revealed a lack of understanding of their significance. The Infection Preventionist could not provide documentation of training, and some nurse aides were not included in the education records. The DNS and Regional Nurse confirmed that staff should verbalize the meaning of the stickers, as per policy.
The facility failed to offer the 2023-24 COVID-19 vaccine to residents, as documented in the clinical records of five residents. Interviews revealed a lack of communication and documentation regarding vaccine education and consent. The prior Administrator cited an unverified FDA disapproval as the reason for not offering the vaccine, which was contradicted by the Pharmacy Representative. The Medical Director was unaware of the issue, and the facility's policies on vaccination were not adhered to.
The facility failed to notify resident representatives and physicians of significant changes in condition for multiple residents. One resident's representative was not informed of new medical orders following a change in condition, while another resident's physician was not notified when a medication was held without parameters. Additionally, a resident's aggressive behavior was not reported to the physician or psychiatric provider, despite the potential impact on care.
A resident with schizophrenia and impaired cognition was stabbed in the neck with a fork by their roommate, who had major depressive disorder and PTSD, in a LTC facility. The attacking resident was disoriented and making nonsensical statements prior to the incident, which was reported to a nurse. The facility failed to prevent the abuse, despite warning signs of the attacking resident's altered mental state.
A resident with schizophrenia was attacked by another resident with PTSD using a fork, resulting in a neck abrasion. The incident was witnessed and reported internally, but the facility failed to notify the State Survey Agency within the required timeframe, violating state law and facility policy.
A facility failed to conduct a Level II PASARR rescreen for a resident after a new diagnosis of schizophrenia, despite federal requirements. The resident, admitted with previous mental health diagnoses, was not evaluated following the change, and the clinical record lacked evidence of psychiatric consultation in the months following the diagnosis. Interviews revealed that staff were unaware of the need for a rescreen, highlighting a deficiency in compliance with PASARR requirements.
The facility failed to conduct proper assessments for two residents after unwitnessed falls, neglecting required neurological and post-accident assessments. Additionally, a resident did not receive medication as per physician's orders, with the LPN holding the medication without proper parameters or physician notification.
The facility failed to maintain and store respiratory equipment properly for three residents with COPD and other conditions. Oxygen tubing for a resident was not changed as per physician orders, and nebulizer and BiPAP masks for two residents were not stored in a sanitary manner. Interviews confirmed these deficiencies, and no policy for equipment care was provided.
A facility failed to maintain accurate fluid intake records for a resident on a fluid restriction due to end-stage renal disease and congestive heart failure. Despite physician orders for a 1000ml daily fluid limit, the Intake and Output log showed missing documentation for several shifts. Interviews revealed inconsistencies in staff responsibilities for recording intake, with nurse aides and charge nurses both involved but lacking clear accountability. The facility's policies required accurate documentation, yet the records were incomplete, indicating a breakdown in compliance with medical orders.
The facility did not complete annual performance reviews for nurse aides in 2023, as required by policy. The HR Director and DNS, both new to the facility, were unaware of the previous year's reviews, and the staff development nurse responsible for them was no longer employed. The Administrator, also new, acknowledged the issue, which was contrary to the facility's policy of conducting formal reviews annually.
Failure to Supervise Resident with Dementia Resulting in Elopement and Exposure
Penalty
Summary
A resident with dementia, moderate cognitive impairment (BIMS score of 10), and a court-appointed conservator was admitted with multiple diagnoses including cardiomyopathy, nicotine dependence, and chronic kidney disease. The resident was care planned for dementia, poor judgment, and required assistance with activities of daily living (ADLs), but was noted to ambulate independently. There were no physician orders for a leave of absence, and the resident was not identified as an elopement risk by staff. On the day of the incident, the resident was last seen by staff in the dining room and lobby around 5:40 PM, wearing two coats and shoes, but left the facility at 5:36 PM as confirmed by video footage. Staff did not notice the resident's absence until notified by local police at 8:15 PM, over two hours later. The resident was found by police approximately half a mile from the facility, lying face down in a snowbank, confused, wet, and missing a shoe. Emergency services responded, removed wet clothing, and transported the resident to the hospital, where the resident was diagnosed with a fall and frostnip. The resident reported leaving the facility to buy cigarettes but could not recall the timing or duration of the absence. The outside temperature at the time was 13°F with light snow, and the resident was found in a residential area along a main road with a 45 mph speed limit. Documentation and interviews revealed that staff did not monitor the resident's whereabouts or meal consumption after the resident left the facility. Nursing assistants and nurses assumed the resident was either in their room or visiting another unit, as the resident often ate meals later and ambulated independently. There was a lack of communication between dining room and unit staff regarding the resident's location and meal intake. The facility was unable to provide a policy regarding routine monitoring of residents for safety, and there was no documentation of ADL tasks for the resident during the relevant shift. Staff were unaware of the resident's absence for 2 hours and 39 minutes until police notification.
Failure to Notify Medical Provider of Admission Denial and Medication Omissions
Penalty
Summary
The facility failed to notify the Medical Director when a resident, who had been accepted for admission, was denied entry after arrival. The resident, with diagnoses including acute respiratory failure, acute decompensated heart failure, and moderate malnutrition, was transferred from an acute care hospital to the facility by ambulance. Upon arrival, the nursing supervisor was not aware of the pending admission, and the resident was not in the facility's electronic medical record system. Despite having the necessary paperwork from the ambulance personnel, the staff could not process the admission and believed the resident was sent to the wrong facility. The resident was ultimately not admitted, left the facility, and the Medical Director was not notified of the situation until after the resident had departed. Additionally, the facility failed to ensure provider notification when a resident's medication, pregabalin, was omitted on twenty-four occasions. The resident, who had chronic pain and neuropathic pain, had a physician's order for pregabalin three times daily. Review of the Medication Administration Record and nurse's notes revealed multiple missed doses over February and March, with no documentation that a provider was notified of the omissions. Interviews with the medical provider and APRN confirmed they were not informed of the missed doses, and both indicated they would have considered alternative pain management if notified. Facility policy required notification of the attending physician or Medical Director in the event of significant changes in a resident's condition, including medication omissions. However, in both cases, the required notifications were not made, and there was no documentation of provider contact regarding the issues. The failures were confirmed through clinical record reviews, facility documentation, and staff interviews.
Failure to Administer Pain Medication as Ordered Due to Prescription and Supply Errors
Penalty
Summary
A deficiency occurred when a resident with chronic and neuropathic pain was not administered pregabalin as ordered by the provider, resulting in 24 missed doses over a six-week period. The provider's order specified pregabalin 200 mg to be given orally three times daily, but medication administration records and controlled substance logs revealed multiple omissions. The resident was cognitively intact, independent with activities of daily living, and experienced frequent pain, for which scheduled and as-needed pain medications were prescribed. The missed doses were traced to a series of events involving a prescription error and subsequent supply issues. On one occasion, a prescription was sent to the pharmacy with incorrect directions, stating pregabalin should be administered once daily at bedtime for constipation, rather than three times daily for pain. This error led to the pharmacy dispensing a limited supply and subsequent refill attempts being denied as 'too soon.' The pharmacy did not question the unusual prescription instructions, and the facility did not obtain an alternative medication when pregabalin was unavailable. Interviews with facility staff, the provider, and the pharmacy confirmed awareness of the missed doses and the prescription error. The facility's medication administration policy required immediate physician notification and documentation if a medication was unavailable, but there was no evidence these steps were taken. Documentation of the written or electronic prescriptions sent to the pharmacy was not provided for review.
Failure to Admit Resident Due to Breakdown in Admission Communication and Procedures
Penalty
Summary
A resident with diagnoses including acute respiratory failure, acute decompensated heart failure, and moderate malnutrition was transferred from an acute care hospital to the facility for skilled nursing services. The resident arrived by ambulance, was placed in a room, and the transfer of care was completed by EMS to facility staff. However, the facility staff were not aware of the pending admission prior to the resident's arrival, as the required notification and documentation were not received through the facility's centralized admissions process. The resident's information did not appear in the electronic medical record system, preventing staff from completing the admission process. The nursing supervisor on duty did not obtain a report from the hospital prior to the resident's arrival and did not contact the hospital after the resident arrived. Believing the resident may have been transported to the wrong facility due to the lack of paperwork and system notification, the supervisor contacted the DON and Administrator. The resident, who was alert and oriented, was asked to leave the facility after refusing to return to the hospital, and ultimately left to return home. The DON was later informed of the situation and attempted to contact the resident after learning of the misunderstanding regarding the admission. Interviews revealed that the admissions coordinator had not sent the required notification to the facility due to employee error, and there was no established process for contacting the on-call admissions contact after business hours. The medical director was not notified of the admission issue until after the resident had left the facility, contrary to expectations for provider notification in such situations. The lack of communication and failure to follow established admission procedures resulted in the resident not being admitted as intended.
Resident Left Unattended During Ambulation Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, difficulty walking, weakness, osteoporosis, and chronic pain, who was assessed as a fall risk and required assistance of one staff member with a rolling walker for ambulation, was left unattended while ambulating without an assistive device. The resident's care plan and physician's orders specified the need for staff assistance and use of a rolling walker, and interventions included encouraging the resident to wait for staff assistance and to use proper footwear and mobility aids. Despite these directives, the resident was observed pushing a wheelchair for stability, then left the wheelchair and began walking unaided in the hallway. A nurse aide, aware of the resident's need for assistance, left the resident's side to retrieve the wheelchair, during which time the resident was not within the staff's line of sight. Another staff member, who had observed the resident ambulating alone, instructed the nurse aide to get the wheelchair but did not remain to supervise. As a result, the resident fell, sustaining a right humerus fracture and a laceration to the right eyebrow, requiring hospital treatment. Facility policy required ambulation according to the care plan and supervision as needed, but these were not followed at the time of the incident.
Failure to Ensure Timely Orthopedic Follow-Up After Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with anoxic brain damage, muscle weakness, and anxiety disorder sustained a fall resulting in a right tibial/ankle fracture. Following the fall, the resident was evaluated in the Emergency Department (ED), where a splint was placed and clear instructions were given for orthopedic follow-up within one week. Despite these directives, a review of the clinical record and facility documentation revealed that no order for orthopedic follow-up was entered, and there was no evidence that the orthopedic office was contacted or that the resident attended a follow-up appointment within the recommended timeframe. The resident did not receive an orthopedic evaluation until over two months after the injury, at which point the orthopedic provider noted that the splint had been left in place for an extended period and expressed concern about the lack of timely follow-up. Interviews with facility staff confirmed that nursing was responsible for arranging the appointment, but the process was overlooked, and the delay was not identified until much later. The facility was unable to provide policies regarding following physician's orders and arranging outside appointments when requested.
Failure to Inspect Skin Under Splint Leads to Pressure Ulcer
Penalty
Summary
A deficiency occurred when staff failed to inspect a resident's skin following the application of a splint, contrary to facility policy, which resulted in the development of a stage 2 pressure ulcer. The resident, who had diagnoses including anoxic brain damage, muscle weakness, and anxiety disorder, required extensive assistance with mobility and was dependent on staff for transfers. After sustaining a right tibial fracture and receiving a soft cast, there was no documented order to assess the skin under the splint, and nursing notes did not indicate that skin checks were performed beneath the device during the period it was in place. Facility documentation and interviews revealed that weekly body audits and shift assessments were either not completed or did not mention the presence of the soft cast or the condition of the skin underneath. The splint remained in place for approximately two and a half months without documented skin assessments, and the first outpatient evaluation since the injury occurred only after this period. Upon removal of the splint, a stage 2 pressure ulcer was discovered on the resident's right lateral ankle, which required wound care intervention. Interviews with facility staff, including the prior DNS, APRN, and wound care physician, confirmed that it was expected practice to check the skin under removable splints or casts every shift and document these assessments. However, there was no order in place to do so, and staff did not document that such checks were performed. The lack of skin inspection and documentation directly contributed to the development of the pressure ulcer under the splint.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and documentation reviews. During an initial tour, surveyors noted stains, dirt, debris, and food debris on the floors in the hallways leading to the lobby and across all four unit hallways. Further inspections revealed damaged, chipped, and stained walls in numerous resident rooms and common areas, as well as damaged and peeling doors, rusty radiators, and stained or torn curtains. Additionally, there were issues with sticky floors, wax buildup, and spider webs, indicating a lack of thorough cleaning and maintenance. The infection control surveillance and safety rounds worksheet, completed by RN #1 and the Housekeeping Manager, documented that the resident rooms and common areas did not meet cleanliness standards. However, the forms did not specify which units were inspected. Interviews with facility staff, including the Infection Preventionist, Administrator, and Housekeeping Manager, confirmed awareness of these environmental issues. The Administrator, who had been with the facility for a short time, acknowledged the need for a plan to address these concerns, while the Housekeeping Manager, employed for approximately two months, indicated plans for meetings to discuss cleanliness and repairs. On the Ambrosia Unit, surveyors observed cable TV wiring hanging below television screens, obstructing views and posing potential hazards. The Administrator and Housekeeping Manager explained that the wiring was necessary for the current cable provider's equipment but anticipated the issue would be resolved with a new provider. Despite requests, the facility did not provide a policy for maintaining a safe, clean, and homelike environment, nor did they provide job descriptions for the housekeeping manager. The facility's infection control policy required quarterly surveillance rounds, but the lack of specific documentation and follow-through contributed to the ongoing deficiencies.
Emergency Exit Obstruction and Incomplete Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that one of the two emergency exit points on a resident unit was free of equipment and clutter, which obstructed access to the exit doors. During an initial tour, it was observed that the emergency exit doors located at the end of the west side corridor were blocked by soiled linen/trash carts, a stand assist device, wheelchairs, and Hoyer lifts, leaving only 18-24 inches of space between the equipment. This obstruction was confirmed during interviews with the Director of Nursing Services (DNS) and the Administrator, who acknowledged that the corridor should have been clear to allow full access to the emergency exit and fire extinguisher. Despite initial corrective actions to clear the corridor, subsequent observations revealed that the emergency exit doors were again partially blocked on multiple occasions. Equipment such as soiled linen/trash carts, wheelchairs, and a Hoyer lift continued to obstruct the corridor, compromising access to the emergency exit doors and fire extinguisher. The DNS admitted that additional staff education was necessary to ensure compliance with the facility's fire safety policy, which mandates that all passageways, corridors, and fire door exits remain unobstructed. Additionally, the facility failed to complete timely fall risk assessments for a resident with a history of multiple falls and injuries. The resident, who had diagnoses including a history of falling and muscle weakness, experienced several unwitnessed falls, some resulting in injuries such as a nasal fracture and a clavicle fracture. The clinical record showed that fall risk assessments were not consistently completed following each fall, contrary to the facility's policy, which requires assessments upon admission, quarterly, annually, and after significant changes in condition or following a fall. The DNS acknowledged the oversight in completing the necessary assessments for the resident.
Failure to Ensure Staff Understanding of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff understood the protocol for informing personnel and visitors about residents on Enhanced Barrier Precautions (EBP). During the survey, it was observed that five rooms with residents on EBP did not have visible signage at the entrance. Instead, the facility used orange circular stickers on the resident name plates to maintain resident dignity. However, RN #1, the assigned Infection Preventionist, could not provide documentation of training for staff and visitors on the use of these stickers. Interviews with several licensed staff and nurse aides revealed a lack of understanding of the significance of the orange stickers. Additionally, a review of the education records showed that some nurse aides were not included in the documented training. The Director of Nursing Services (DNS) and Regional Nurse confirmed that staff should be able to verbalize the meaning of the stickers, as per facility policy, which requires visible signage and education on EBP. The deficiency was identified due to the lack of staff knowledge and documentation regarding the EBP protocol.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to accept or refuse the 2023-24 COVID-19 vaccine during the fall/winter virus season. This deficiency was identified for five residents whose clinical records did not document that they were provided education on the benefits of the COVID-19 booster, nor was there any signed consent or refusal documentation. The residents' immunization records showed that the last COVID-19 booster was either refused or administered in previous years, with no updates for the 2023-24 season. Interviews with facility staff, including the Infection Control Nurse (RN #1), the prior Facility Administrator, and the Director of Nursing Services (DNS), revealed a lack of documentation and communication regarding the offering of the COVID-19 vaccine. The prior Administrator mentioned a canceled vaccine clinic due to an alleged FDA disapproval, which was not corroborated by the Pharmacy Representative, who stated that vaccines were available and no recall or disapproval had occurred. The DNS confirmed that the vaccine was not offered to residents or staff during the entire season, and there was no investigation into approved alternatives. The Medical Director was unaware of the situation and emphasized the importance of vaccine education and recommendation. The facility's COVID-19 policy encourages staying up to date with vaccinations, and the vaccination policy directs that vaccines be offered in accordance with CDC guidance. However, these policies were not followed, leading to the deficiency in ensuring residents had the opportunity to receive the COVID-19 vaccine.
Failure to Notify Resident Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representative of Resident #8 when there was a change in the resident's condition that required new medical orders. Resident #8, who had a history of heart failure, atrial fibrillation, and pulmonary embolism, experienced increased coughing and a loss of voice. The APRN ordered a chest x-ray, nebulizer treatments, and new medications, but there was no documentation that the resident representative was informed of these changes. This lack of communication persisted despite multiple new orders and changes in the resident's condition over several days. For Resident #65, the facility did not ensure that the physician was notified when a medication for low blood pressure, Midodrine, was held without parameters. The resident had a history of anemia and cardiovascular issues, and the medication was not administered on several occasions due to the nurse's decision based on blood pressure readings. However, there were no documented parameters for holding the medication, and the physician was not informed of these omissions, which occurred multiple times over a period of weeks. Additionally, the facility failed to notify the attending physician and psychiatric provider when Resident #31, who had a history of major depressive disorder and PTSD, exhibited aggressive behavior. After returning from the hospital with a diagnosis of acute encephalopathy, Resident #31 attacked another resident with a fork and made a threatening gesture towards a nurse aide. Despite the severity of the incident, there was no documentation that the physician or psychiatric provider was informed of the behavior, which could have been critical for the resident's ongoing care and management.
Resident Stabbed by Roommate Due to Facility's Failure to Prevent Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in an incident where one resident was stabbed in the neck with a fork by their roommate. The resident who was attacked had diagnoses including schizophrenia and anxiety disorder, and was noted to have severely impaired cognition and required assistance for mobility. The attacking resident had diagnoses of major depressive disorder, PTSD, and mild cognitive impairment, but was noted to have intact cognition and independence in activities of daily living. Prior to the incident, the attacking resident had been disoriented and was making nonsensical statements, which was reported to a nurse by a speech-language pathologist. The incident occurred when the attacking resident approached the other resident and stabbed them with a fork, causing an abrasion to the neck. The attack was witnessed by a nurse aide who intervened and secured the fork. The attacking resident was disoriented and made threatening gestures following the incident. The facility's abuse policy mandates immediate notification of the Director of Nursing Services or Administrator upon witnessing abuse, completion of an incident report, and an investigation. However, the report highlights a failure in preventing the abuse from occurring, despite the presence of warning signs of the attacking resident's disorientation and altered mental state.
Failure to Report Resident Abuse Incident Timely
Penalty
Summary
The facility failed to immediately report a witnessed incident of abuse to the State Survey Agency, as required by state law. The incident involved Resident #31, who attacked Resident #11 with a fork, causing an abrasion to the neck. Despite the attack being witnessed and documented, the facility did not notify the State Survey Agency within the mandated 2-hour timeframe. The Director of Nursing Services (DNS) acknowledged the oversight in notification, which was a violation of the facility's abuse policy that mandates immediate reporting of any abuse or mistreatment. Resident #11, who has diagnoses including schizophrenia and anxiety disorder, was attacked by Resident #31, who has major depressive disorder and PTSD. At the time of the incident, Resident #31 was disoriented and had recently returned from the hospital with a diagnosis of acute encephalopathy. The attack was witnessed by a nurse aide, who intervened and reported the incident to the charge nurse. Despite the immediate separation of the residents and notification to the police and resident representatives, the facility failed to report the results of the investigation to the State Survey Agency within 5 working days, as required.
Failure to Conduct PASARR Rescreen After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a rescreen PASARR for a resident following a new diagnosis of schizophrenia on January 13, 2022. The resident, who was admitted in August 2019, had previous diagnoses including delusional disorder, paranoid personality, and anxiety disorder. Initially, a PASARR Level I screening conducted in August 2019 did not require a Level II evaluation. However, after the new diagnosis of schizophrenia, the facility did not conduct a Level II PASARR screening as required. Additionally, the clinical record did not show that the resident was seen by psychiatry in January or February 2022 following the new diagnosis. Interviews with the Director of Nursing Services (DNS) and the social worker revealed a lack of awareness regarding the need for a PASARR rescreen following the resident's change in mental health diagnosis. The social worker acknowledged that a PASARR rescreen referral should have been completed at the time of the diagnosis change. The facility's PASARR policy, which aligns with federal requirements, mandates evaluations for mental illness to ensure appropriate placement and services. The oversight in conducting a Level II PASARR evaluation represents a deficiency in adhering to these requirements.
Deficiencies in Fall Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure proper assessments and follow-up care for residents who experienced unwitnessed falls. Resident #19, who had severe cognitive impairment and was at risk for falls, experienced an unwitnessed fall. However, the clinical record did not reflect that a registered nurse conducted an assessment following the fall, nor were any neurological assessments or additional post-accident and incident (A&I) assessments completed as per facility policy. Resident #26, with a history of falls and moderate cognitive impairment, experienced multiple unwitnessed falls. The facility's documentation was incomplete, lacking necessary neurological assessments and post A&I monitoring for several incidents. Despite the facility's policy requiring such assessments, they were not conducted, and the documentation was inconsistent and incomplete, failing to provide a clear record of the resident's condition following the falls. Additionally, the facility failed to administer medication as per physician's orders for Resident #65, who had moderately impaired cognition and was at risk for cardiac issues. The medication Midodrine was not administered on several occasions without proper parameters or physician notification. The LPN held the medication based on personal judgment rather than documented medical guidelines, and there was no facility policy to support this decision. The DNS was unaware of these omissions, indicating a lack of communication and oversight in medication administration procedures.
Deficiencies in Respiratory Equipment Maintenance and Storage
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a clean and sanitary manner and did not change respiratory equipment according to physician orders for three residents. Resident #11, who had chronic obstructive pulmonary disease (COPD) and heart failure, was observed with oxygen tubing that had not been changed for 20 days, despite physician orders to change it weekly. Interviews with LPNs and the Director of Nursing Services (DNS) confirmed that the tubing should have been changed weekly, but no policy detailing the care and management of oxygen equipment was provided. Resident #18, who had COPD and a history of stroke, was found with a nebulizer mask placed on a bedside table without a label or cover, contrary to the expectation that it should be stored in a plastic bag when not in use. Similarly, Resident #39, who had COPD and a recent history of pneumonia, had a BiPAP mask on the floor and a nebulizer mask uncovered on the bedside table. Interviews confirmed that these items should have been stored in a bag when not in use, and a physician's order for the use of the BiPAP machine was not located. The facility did not provide a policy for the care and management of oxygen equipment despite requests.
Failure to Maintain Accurate Fluid Intake Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain an accurate daily fluid intake record for a resident on a fluid restriction. Resident #14, who was admitted with diagnoses including end-stage renal disease and congestive heart failure, was on a physician-ordered fluid restriction of 1000ml in 24 hours. Despite this, the facility's Intake and Output log showed missing documentation for several shifts throughout September 2024, indicating a failure to accurately monitor and record the resident's fluid intake. Interviews with facility staff revealed inconsistencies in the responsibility for documenting fluid intake. Nurse aides were expected to record intake totals, but the charge nurse was ultimately responsible for ensuring documentation was complete. However, several shifts lacked recorded intake totals, and staff interviews indicated a lack of clarity and accountability in maintaining these records. The facility's policy required that all nursing personnel record intake and output, with the nurse responsible for completing subtotals at the end of each shift. The facility's Hemodialysis policy also required maintaining fluid restrictions and monitoring intake and output, yet the documentation was incomplete. The DNS and RN Supervisor both expressed expectations that intake totals be documented and monitored, but the failure to do so was evident in the missing records. This deficiency highlights a breakdown in the facility's processes for ensuring compliance with physician orders and maintaining accurate health records for residents requiring specialized medical treatment.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete performance reviews for nurse aides once every 12 months, as required by their policy. A review of facility documentation, including nurse aide personnel files, indicated that performance reviews were not conducted for the year 2023. Interviews with the HR Director and the Director of Nursing Services (DNS) revealed that the HR Director was new to the facility and was unsure about the previous year's performance reviews. The DNS mentioned that the staff development nurse, who conducted the reviews last year, was no longer working at the facility. The Administrator, also part of the new management team, acknowledged the oversight and indicated that performance reviews would be addressed in the future. The facility's policy mandates a formal and documented performance review at the end of an employee's introductory period and annually thereafter, emphasizing the importance of these reviews for discussing work expectations, results, and goals with supervisors.
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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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Illustrative
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Nursing homes near Rocky Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 60 West | 0.7 mi | ★★★★★ | 0 | 0 |
| John L. Levitow Health Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Maple View Health & Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Salmon Brook | 4.1 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Cromwell | 4.4 mi | ★★★★★ | 0 | 0 |
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