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 Shelton Lakes during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was discharged home with a roommate’s Seroquel blister pack labeled with the roommate’s name and drug name. The family later reported the resident took the wrong medication and became lethargic, and record review showed the resident was not prescribed Seroquel. An LPN stated she gathered the discharge meds from the med cart but did not check them before giving them to the family member, and the DNS stated the nurse should review the discharge meds and instructions.
Medication Error During Discharge: A resident with severe cognitive impairment was discharged home with a family member and later found to have received another resident’s Seroquel instead of the correct meds. The LPN gathered blister packs from the med cart but did not verify them before handing them over, and the resident’s roommate was the one prescribed quetiapine. After the family reported lethargy and the wrong medication, the resident was sent for medical evaluation.
A resident with severe cognitive impairment and a need for set-up assistance with showers was scheduled to receive weekly showers and preferred this method of bathing. Over a two-month period, documentation showed the resident received only two out of nine scheduled showers, with no records indicating showers were provided, refused, rescheduled, or that alternative hygiene measures were offered for the remaining dates. Facility policy required weekly bathing offers and proper documentation, which was not followed.
A resident with severe cognitive impairment and psychiatric diagnoses was not included, nor was their representative, in the development and implementation of their person-centered care plan. Required interdisciplinary team meetings were not documented or held within policy timeframes, and staff could not provide evidence or explanation for the omission, despite facility policy mandating collaborative care planning with the resident and/or family.
The facility failed to maintain a safe, clean, and homelike environment, with observations of stained and discolored toilet seats, marred walls, and stained tiles in various rooms. The Director of Maintenance was unable to provide documentation of environmental rounds or a plan to address these issues. Additionally, concerns about stained ceiling tiles were confirmed, although no mold was found. The facility's policy required department heads to correct identified issues, but no specific policy for maintaining cleanliness was provided.
A resident with CHF did not have daily weights conducted as per physician orders, with only partial compliance over three months. The ADNS could not explain why weights were signed off as completed but not documented, indicating a lapse in oversight and documentation.
The facility failed to provide timely audiology services for several residents, resulting in untreated hearing issues. Residents with cognitive impairments and other diagnoses were not evaluated due to missing physician's orders and lack of follow-up on recommendations. The DNS and Social Worker did not effectively oversee the process, leading to systemic issues in coordinating outside medical appointments.
The facility failed to properly store and label IV therapy supplies, with observations revealing loose heparin and saline flushes stored incorrectly, expired supplies, and mislabeled boxes. The Infection Preventionist acknowledged the issues, including the need to return resident-specific supplies after discharge. Additionally, a policy for drug destruction was not provided.
The facility failed to maintain sanitary food service practices and proper food storage. A dietary aide reused a plate cover for multiple meals, and another aide touched the inside of the cover with bare hands. Additionally, opened food items in the refrigerator were not dated, and dented cans were found in the dry storage room, violating facility policies.
The facility failed to adhere to infection control standards for catheter management and enhanced barrier precautions. A resident's urinary collection device was improperly placed on the floor, and another resident's Foley catheter bag was uncovered. Additionally, residents requiring enhanced precautions lacked proper signage and PPE availability, leading to staff confusion. During wound care, staff did not follow gowning protocols for a resident on enhanced precautions.
The call bell system in the rehabilitation wing failed to relay calls to the nursing station, lighting up outside rooms but not sounding at the station. Staff were unaware of the error message, and maintenance identified a malfunctioning part needing replacement. Facility records showed delays in repair due to part shipment issues, and previous repair documentation was unavailable.
Two residents with urinary collection devices were not treated with dignity, as their devices were left uncovered and visible. One resident, who was moderately cognitively impaired, had their urine collection device exposed to view from the open room door. Another resident, who was cognitively intact, had their Foley bag uncovered on the floor. Facility staff were unaware of the requirement for privacy covers, contrary to the facility's policy.
A facility failed to update the care plan for a resident who elected Hospice/End of Life services. Despite being admitted to hospice care, the resident's MDS assessment did not reflect this change. The Social Worker did not find a Hospice care plan in the resident's record, and the MDS Coordinator did not initiate one as required. Facility policy mandates care plans be updated to reflect changes in residents' status, which was not followed.
A resident with dysphagia experienced significant weight fluctuations, but the facility failed to obtain re-weights as required by their policy. Despite a 5-pound discrepancy threshold, re-weights were not consistently conducted, and staff interviews revealed a lack of adherence to the policy. The dietician and nursing staff did not ensure proper weight monitoring, leading to the deficiency.
Discharge Medication Mix-Up Breached Resident Confidentiality
Penalty
Summary
The facility failed to maintain resident privacy and confidentiality when a resident was discharged home with a roommate’s medication that was labeled with the roommate’s name and drug name. Resident #1 had diagnoses including Alzheimer’s disease, urinary tract infection, and diabetes, and the discharge MDS showed a BIMS score of 0/15, indicating severe cognitive impairment, with dependence for ADLs and assistance needed for ambulation. Resident #2, the roommate, had diagnoses including dementia, anxiety, restlessness, and agitation, and had a physician order for Quetiapine Fumarate (Seroquel) 50 mg, two tablets daily for mood disorder. Resident #1 was discharged home with family assistance, and the discharge paperwork was signed by the family member. After discharge, the facility received a call from a family member reporting that Resident #1 had taken the wrong medication and was lethargic. The facility APRN was notified and advised that Resident #1 be sent to the hospital for evaluation. Record review showed Resident #1 was not prescribed Quetiapine Fumarate, yet a blister card labeled Seroquel was found among the medications sent home, and the family member stated the medication had been given the night before. An LPN stated she gathered Resident #1’s medication blister packs from the medication cart during discharge and did not check the medications before handing them to the family member. She later learned that Resident #1 had been sent home with Seroquel and that the medication likely belonged to the roommate. The DNS stated the nurse should review discharge instructions and medications being sent home and ensure the person receiving education is attentive. The facility’s resident rights policy stated residents have the right to privacy and confidentiality regarding personal and health information.
Medication Error During Discharge
Penalty
Summary
The facility failed to ensure a resident’s medications were reviewed before discharge so that the correct medications were sent home with the resident. Resident #1 had diagnoses including Alzheimer’s disease, urinary tract infection, and diabetes, and the discharge MDS identified severe cognitive impairment with a BIMS score of zero, dependence for ADLs, and need for assistance with ambulation. The care plan identified the resident was admitted for short-term rehabilitation and included discharge planning interventions for home care services and needed equipment. Resident #1 was discharged home with a family member, and the discharge paperwork was signed by the family member. After discharge, the facility received a report that the resident had taken the wrong medication and was lethargic. The facility investigation identified that the resident had been sent home with another resident’s medication, specifically a blister card labeled Seroquel. The resident was not prescribed Quetiapine Fumarate, while the roommate was prescribed Quetiapine 50 mg, two tablets daily for mood disorder. Facility documentation and interviews showed the medication error occurred during discharge when the LPN gathered the resident’s blister packs from the medication cart and did not check the medications before handing them to the family member. The LPN stated the resident was not on Seroquel and later learned the medication sent home belonged to the roommate. The DNS stated staff should review discharge instructions and the medications being sent home with the resident, and the facility record identified the medication error as sending the resident home with someone else’s medications.
Failure to Provide and Document Weekly Showers for Resident Requiring ADL Assistance
Penalty
Summary
A resident with diagnoses including dementia, cerebral infarction, and anxiety disorder, and a BIMS score indicating severe cognitive impairment, was identified as requiring set-up assistance for showers and had a care plan specifying assistance with activities of daily living (ADLs). The resident's care card scheduled weekly showers and noted a preference for showers. However, documentation review for a two-month period showed that out of nine scheduled weekly shower opportunities, the resident received only two showers. There was no documentation for the remaining seven scheduled shower days to indicate that a shower was provided, refused, rescheduled, or that alternative hygiene measures were offered. Further review of clinical records did not reveal any evidence that the resident refused showers on the missed dates, nor was there documentation of staff re-attempting or notifying the nurse as required by facility policy. The DON confirmed that if a shower is not documented as given or refused, it is considered not performed. The facility's Bathing/Shower Policy requires that each resident be offered a full bath or shower at least weekly, with staff responsible for assisting and ensuring safety throughout the process.
Failure to Include Resident and Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure the inclusion of a resident and/or their representative in the development and implementation of a person-centered care plan. Clinical record review showed that a resident with schizophrenia and depression, who had severe cognitive impairment and was dependent on personal care, was admitted with a designated responsible party holding Power of Attorney. The care plan directed family involvement, but there was no documentation of any interdisciplinary team (IDT) meetings from admission through several months, despite facility policy requiring such meetings within specific timeframes. The facility was unable to provide evidence that an admission care plan meeting or any subsequent meetings occurred as required. A social services note eventually documented a telephone care plan meeting with the responsible party, and a later IDT care plan meeting document failed to clarify if the resident or their representative were present or invited. Interviews with staff confirmed that required care plan meetings had not been conducted as per policy, and they could not explain the omission. Facility policy explicitly required inviting the resident and/or family to all care plan conferences and developing the care plan collaboratively, but this was not followed in the resident's case.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. On December 2, 2024, various rooms were found with discolored and stained toilet seats, marred walls, stained tiles, and other forms of damage such as exposed sheetrock and rusted metal trim. Additionally, brown stains were observed on curtains and walls, and some areas had missing or damaged baseboards. The Director of Maintenance acknowledged responsibility for overseeing maintenance and housekeeping but could not provide documentation of environmental rounds or a plan to address these issues. The facility's policy for Infection Control Surveillance and Safety Rounds required regular surveillance by the infection control nurse or designee, with department heads responsible for correcting identified issues, but no specific policy for maintaining a clean environment was provided. Further concerns were raised through the state agency's online reporting system regarding stained ceiling tiles and potential mold in ceiling registers. A tour on December 4, 2024, confirmed the presence of scattered stained tiles, including a cracked tile in the chapel and stained tiles in the resident lounge and hallway. However, no mold was observed by the state agency's Building Fire and Safety inspection team. The facility's policy indicated that department heads were responsible for addressing issues identified during surveillance rounds, but the report does not mention any corrective actions taken to resolve these deficiencies.
Failure to Conduct and Document Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to consistently conduct daily weights for a resident with Congestive Heart Failure (CHF) as per physician orders. The resident, who is cognitively impaired and requires assistance with personal hygiene and dressing, had a physician's order for daily morning weights due to CHF. However, a review of the clinical records revealed that the facility only conducted 4 out of 8 daily weights in December, 7 out of 30 in November, and 14 out of 31 in October. This inconsistency in monitoring the resident's weight, which is crucial for managing CHF, was not in compliance with the physician's orders. Interviews with the Assistant Director of Nursing Services (ADNS) revealed that weights are documented in the facility's electronic records, and if a resident refuses, it should be noted in the progress notes. Despite the expectation that weights are documented, the ADNS could not explain why daily weights were signed off as completed but not documented in the clinical record. The charge nurse, ADNS, and Director of Nursing Services (DNS) are responsible for ensuring that tasks are completed, indicating a lapse in oversight and documentation processes within the facility.
Failure to Ensure Timely Audiology Services for Residents
Penalty
Summary
The facility failed to ensure that residents received proper treatment to maintain adequate hearing, as evidenced by the cases of five residents. Resident #16, who was diagnosed with dementia and major depressive disorder, was identified as severely cognitively impaired and required assistance with activities of daily living. Despite being placed on a list for an audiology visit, the resident's hearing loss could not be evaluated due to ear wax, and recommendations for wax removal were not followed up. The Social Worker responsible for overseeing medical specialty services did not follow up on the provider requests, and the Director of Nursing Services (DNS) was unaware of the concerns related to residents not being seen or recommendations not being followed. Resident #18, diagnosed with anxiety disorder and arteriosclerosis, was cognitively intact but dependent on assistance for daily activities. The resident refused services initially and was rescheduled, but the evaluation could not proceed due to the absence of a physician's order. The Administrator and DNS acknowledged that the contracted vendor appointments are initiated upon admission, and the DNS is responsible for overseeing the process, but there was a lack of timely follow-up. Resident #23, with dementia and cataracts, was scheduled for an audiology consultation due to decreased responsiveness, but the evaluation did not occur due to missing physician's orders. Similarly, Resident #76, diagnosed with hypertension and Alzheimer's disease, had a recommendation for wax removal that was not followed up with a physician's order. Resident #83, with cerebral infarction and dementia, also had hearing loss evaluation hindered by ear wax, and there was no follow-up on the recommendations. The facility's policy for outside medical appointments was not effectively implemented, leading to a systemic issue of inadequate follow-up on audiology services.
Improper Storage and Labeling of IV Supplies
Penalty
Summary
The facility failed to ensure that Intravenous (IV) therapy supplies were stored and labeled appropriately, and that expired supplies were removed from storage. During an observation and interview with the Infection Preventionist (IP) RN, it was identified that individually wrapped loose IV heparin and saline flushes were stored in large boxes on a lower shelf, with clear bags containing resident-specific IV flush syringes placed on top. Additionally, central line dressings were scattered behind these boxes. The IP acknowledged that some of these supplies were extra and that certain resident supplies needed to be returned as the residents had been discharged. Further observations in the central supply closet revealed IV supplies in a box without labels indicating whether they were house stock or resident-specific. Another large box contained approximately 100 unused heparin flushes, with two randomly selected flushes showing an expiration date of 2021. The IP admitted responsibility for checking expiration dates and indicated that the supplies would be immediately checked. In the short-term unit medication room, a box labeled for Normal Saline flushes was found to contain Heparin flushes, prompting the IP to instruct the charge nurse to label the flushes correctly. The facility's policy on returning medications to the pharmacy was not followed, as unopened supplies were not returned within the specified timeframe, and a policy for drug destruction was not provided upon request.
Sanitation and Food Storage Deficiencies in Dietary Department
Penalty
Summary
The facility failed to ensure that dietary staff served food in a sanitary manner, as observed during a noon meal service. A dietary aide reused a plate cover for multiple resident meals, holding it against their clothing and placing it upside down on the steam table. Another dietary aide touched the inside of the plate cover with bare hands before plating a meal for another resident. The dietary aides admitted to the breach in sanitary practice, with one aide citing nervousness and a lack of clean covers as reasons for the reuse. The dietary manager confirmed that the facility had enough plate covers and that the practice of reusing them was against the facility's policy. Additionally, during a tour of the dietary department, it was observed that several food items in the walk-in refrigerator were opened without being dated, contrary to the facility's stock rotation policy. Furthermore, 13 dented cans of diced peaches were found in the dry storage room, which should have been removed according to the facility's damaged food container policy. The dietary manager acknowledged these issues, stating that all kitchen staff are responsible for dating opened items and that dented cans should be returned to the vendor.
Infection Control Deficiencies in Catheter and Precaution Management
Penalty
Summary
The facility failed to adhere to infection control standards in the management of urinary catheters for two residents. Resident #28, who was moderately cognitively impaired, was observed with a urinary collection device placed in a basin on the floor without a privacy cover, contrary to physician orders and facility policy. The Director of Nursing Services and a Nurse Aide confirmed the improper placement of the urine collection device. Similarly, Resident #32's Foley catheter bag was repeatedly observed on the floor and uncovered, with staff unaware of the requirement for a privacy bag, indicating a lack of adherence to the facility's catheter care policy. The facility also failed to implement appropriate infection control measures for residents requiring enhanced barrier precautions. Resident #71, who had a urinary tract infection with ESBL, was observed without proper signage or a PPE cart outside the room, leading to confusion among staff about the necessary precautions. The Assistant Director of Nursing and the Infection Preventionist acknowledged the oversight and the need for immediate corrective action. Additionally, Resident #153, who had an indwelling urinary catheter and multiple wounds, was not placed on enhanced precautions upon admission, and no signage was posted to indicate the need for such precautions. Furthermore, the facility did not follow infection control practices during wound care for Resident #2, who had a stage 3 pressure ulcer and was on enhanced barrier precautions. During a wound care procedure, staff failed to gown, as required by the facility's policy, despite the resident's need for enhanced precautions. The Wound APRN and Infection Preventionist admitted to not following protocol during the procedure, highlighting a lapse in infection control practices.
Call Bell System Malfunction in Rehabilitation Wing
Penalty
Summary
The facility failed to ensure that the call bell system on the rehabilitation wing was functioning properly, as it did not relay calls directly to the centralized nursing station. A concern was raised by the state agency indicating that when a call bell was pushed, it would light up above the resident's door but would not ring at the nurse's station. During an observation, it was confirmed that the call lights outside the rooms lit up, but there was no sound at the nurse's station, and an error message was displayed. Staff interviews revealed that the issue was related to a malfunctioning part that needed replacement, and the system required rebooting to function temporarily. The facility records showed that a work order was signed with a vendor for repair of the call bell system, and although the majority of the system was returned to functionality, some areas remained unresolved. The vendor indicated delays in part shipment due to additional spare parts being ordered. The facility was unable to provide documentation regarding previous repairs done by a corporate regional electrician. The facility's policy requires non-functional call bells to be reported to maintenance promptly, and alternative methods of requesting assistance should be provided if there is an extended downtime, which was not documented in this case.
Failure to Ensure Dignity for Residents with Urinary Devices
Penalty
Summary
The facility failed to ensure that residents with urinary collection devices were treated with dignity, as evidenced by observations and interviews involving two residents. Resident #28, who was moderately cognitively impaired and required assistance with activities of daily living, was observed with a urinary collection device without a privacy cover, exposing the device to view from the open room door. The Director of Nursing Services (DNS) was unaware of the requirement for a privacy cover, and a nurse aide admitted to routinely leaving the urine collection device on the floor without a cover. The facility's policy directed that a privacy bag should be used to ensure dignity. Similarly, Resident #32, who was cognitively intact but required maximal assistance for personal hygiene, was observed with an uncovered Foley bag on the floor. A registered nurse was unsure of what a privacy bag was and failed to ensure the Foley bag was covered. The facility's catheter care policy required the use of a privacy bag to maintain resident dignity, which was not adhered to in these cases.
Failure to Revise Care Plan for Hospice Resident
Penalty
Summary
The facility failed to revise the care plan for a resident who elected Hospice/End of Life services. The resident, diagnosed with dementia and arteriosclerotic heart disease, was admitted to hospice care on 11/23/2024. However, the annual Minimum Data Set (MDS) assessment did not reflect this change, as it indicated the resident did not receive Hospice services and did not have a prognosis of six months or less. During an interview and record review on 12/6/2024, it was revealed that the Social Worker responsible for hospice residents did not find a Hospice care plan in the resident's record. The MDS Coordinator was expected to initiate a hospice care plan at the time of the Significant Change MDS, but this was not done. The facility's policy requires care plans to be updated at least quarterly and as necessary to reflect changes in residents' status, which was not adhered to in this case.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to adhere to its policy on weight monitoring for a resident diagnosed with dysphagia, who experienced significant weight fluctuations. Upon admission, the resident's weight was recorded inaccurately, leading to a discrepancy with the hospital discharge weight. Over several months, the resident's weight varied significantly, with gains and losses exceeding the facility's threshold for re-weighing. Despite these fluctuations, re-weights were not consistently obtained as required by the facility's policy, which mandates re-weighing if there is a 5-pound discrepancy from the previous weight. Interviews with the dietician and nursing staff revealed a lack of consistent communication and adherence to the weight monitoring policy. The dietician acknowledged the discrepancies but did not recall requesting re-weights, and the charge nurse indicated that the decision for re-weighing was left to the dietician. The Assistant Director of Nursing Services (ADNS) confirmed that re-weights should have been obtained per policy. The facility's failure to consistently monitor and verify the resident's weight changes as per their policy led to the deficiency identified in the report.
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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 Shelton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hewitt Health & Rehabilitation Center, Inc | 1.2 mi | ★★★★★ | 2 | 0 |
| Gardner Heights Health Care Center, Inc | 2.2 mi | ★★★★★ | 5 | 0 |
| Masonicare At Bishop Wicke Health & Rehabilitation | 2.4 mi | ★★★★★ | 14 | 0 |
| Lord Chamberlain Nursing & Rehabilitation Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Lord Chamberlain Manor Nursing & Rehabilitation Ce | 4.6 mi | ★★★★★ | 5 | 1 |
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