Inspection Reports for
Apple Rehab Laurel Woods

The investigation was complaint-related, focusing on resident-to-resident abuse incidents. The report documents that monitoring and documentation were not completed consistently for the involved residents, and the Director of Nursing acknowledged gaps in staff education and documentation audits.

The facility failed to consistently monitor and document mood, behavior, and skin condition for Residents #1, #2, #3, and #4 following resident-to-resident altercations. Despite interventions and psychiatric evaluations, physician orders and nursing documentation lacked orders and records for monitoring mood, behavior, and skin conditions post-incident.

The complaint investigation was triggered by a report from Resident #1's family member (Person #1) on 3/19/25 regarding unauthorized financial transactions totaling approximately $1735 from Resident #1's PayPal account linked to a facility staff member (NA #1). The facility initiated an internal investigation, notified police, and suspended the employee. Interviews revealed incomplete investigation and failure to interview all relevant parties. Resident #1 had been transferred to hospital on 2/16/25 and subsequently passed away. Person #1 was Resident #1's financial Power of Attorney.

The facility failed to protect Resident #1 from misappropriation when a staff member accessed the resident's phone and transferred money without consent. The facility also failed to fully investigate the allegation by not interviewing all relevant parties and residents to ensure no other residents were affected. Additionally, documentation for Resident #2 was incomplete in the clinical record.

The visit was complaint-related involving Complaint #43298 and #43312. The allegations concerned staff to resident verbal abuse, which was investigated and substantiated by the findings.

The report details findings related to allegations of staff to resident verbal abuse involving Resident #1, including failure to report the abuse timely and inappropriate staff behavior. The facility implemented plans of correction including staff education, audits, and supervision to address these issues.

The complaint involved an allegation of staff to resident verbal abuse. Resident #1 reported an upsetting interaction with NA #1 during the overnight shift on 3/2/25. The allegation was substantiated, and NA #1 was suspended and terminated. The facility failed to report the allegation timely as required.

The facility failed to ensure Resident #1 was not verbally abused by staff and failed to timely report the allegation of verbal abuse to the Administrator or designee within two hours. NA #1 was found to have been argumentative and belligerent during care, and was suspended and terminated. The facility initiated a Plan of Correction including staff training and audits.

The complaint investigation found that Resident #1 was sent unaccompanied to a medical appointment despite requiring assistance and cognitive impairment. The resident was dropped off at the wrong location and later at the emergency department by an unknown person. The facility acknowledged miscommunication and provided employee coaching to involved staff.

The facility failed to ensure Resident #1, who requires assistance and has severe cognitive impairment, was accompanied to a vascular appointment. The resident was sent unaccompanied by transportation, dropped off at the wrong location, and later found at the emergency department. Staff coaching was provided due to this miscommunication and failure to follow policy requiring accompaniment.

The complaint involved an allegation that NA #1 used inappropriate language and hit Resident #1 on the right shoulder. Multiple staff interviews confirmed use of foul language and unprofessional behavior by NA #1, but no direct verbal or physical abuse was substantiated. The allegation was unsubstantiated after review of video footage and investigation.

The investigation found that while inappropriate language and unprofessional behavior occurred, there was no substantiated verbal or physical abuse directed at Resident #1. Video footage did not show direct abuse, and the allegation was unsubstantiated. The nursing assistant involved was terminated due to attendance issues.

The complaint investigation was substantiated with findings that the facility failed to complete timely elopement risk assessments and failed to provide adequate supervision, resulting in a resident eloping from the facility. Immediate jeopardy was identified due to the resident's unsupervised elopement and failure of the front door lock to engage despite the alarm sounding.

The facility failed to complete elopement risk assessments in a timely manner for multiple residents and failed to provide adequate supervision to a cognitively impaired resident who eloped from the building. The front door alarm sounded but the door lock did not engage, and staff failed to respond appropriately to the alarm. Door checks were not performed on weekends, and staff were not fully educated on elopement protocols including the use of the elopement book.

The facility was found deficient in multiple areas including failure to accurately document advance directives, inadequate notification of pressure ulcer changes, failure to prevent and properly investigate resident abuse, incomplete pre-hire background checks, untimely social worker assessments, delayed MDS transmissions, incomplete neurological assessments after falls, failure to obtain physician orders for hospice, inadequate wound assessments, failure to obtain weights per physician orders, improper respiratory equipment handling, incomplete narcotic counts, failure to monitor behaviors with antipsychotic medications, and improper food labeling in the kitchen.

The complaint investigation involved allegations of staff to resident abuse by LPN #8 toward Resident #31, including forceful medication administration and verbal abuse. Additionally, resident to resident abuse incidents occurred between Residents #62, #74, and #76, involving physical altercations and inadequate supervision. The investigation included interviews with staff and review of clinical records and policies.

The facility failed to ensure Resident #31 was free from staff to resident abuse and failed to provide adequate supervision to prevent resident to resident abuse involving Residents #62, #74, and #76. Multiple incidents of physical abuse and altercations were documented, with inadequate investigation and delayed corrective actions.

The facility failed to ensure yearly performance evaluations were completed for two of five licensed nurses reviewed. The Director of Nursing acknowledged that annual evaluations were due but were not completed by the previous DON.

Complaint CT #35828 involved a resident (Resident #1) who left the facility without staff knowledge, was found outside the building, and had a wander guard bracelet in place. The investigation found that the resident exited through a keypad-locked stairwell door with a delay that allowed exit and that staff did not hear the door alarm. The facility identified past non-compliance and implemented corrective actions.

The facility failed to ensure adequate supervision for a resident with severe cognitive impairment who left the facility unsupervised and was found outside. The investigation revealed issues with door security and staff supervision, and the facility implemented interventions to prevent recurrence.

The complaint investigation was substantiated as Resident #1 was observed outside the facility unsupervised after exiting through a keypad-locked door that staff had disabled the alarm for. The facility identified past non-compliance and implemented corrective actions.

The facility failed to ensure adequate supervision for Resident #1, who left the building unescorted through a keypad-locked stairwell door with a delay in relocking, resulting in minimal harm. The investigation revealed staff disabled the door alarm, and no policy was in place for securing stairwell exits. The facility implemented staff education, reduced door delay times, conducted mock drills, and performed audits to prevent recurrence.

Complaint #35310 was investigated and substantiated with findings of noncompliance related to supervision of a resident at risk for choking during meals.

The facility failed to ensure a resident identified at risk for choking was supervised during a meal according to the plan of care. Violations of Connecticut State regulations were identified and a violation letter dated 2023-09-01 was issued.

The complaint investigation found that Resident #1 choked during lunch, was not supervised by nursing staff as required, and required emergency medical intervention. The investigation included interviews with nursing staff, dietary staff, and the Director of Nursing, revealing gaps in supervision and unclear scheduling of nursing presence during meals.

The facility failed to ensure that Resident #1, who was at risk for choking and required supervision during meals, was properly supervised during lunch. Resident #1 choked, became unresponsive, required emergency interventions including the Heimlich maneuver and CPR, and was hospitalized. Interviews revealed nursing staff were not present in the dining room at the time, and dietary staff are not trained to supervise residents while eating.

The complaint investigation found that two residents (Resident #2 and Resident #3) had multiple verbal altercations and a physical altercation on 4/20/2023 resulting in injuries. The facility failed to implement adequate interventions to prevent escalation despite awareness of ongoing conflicts.

The facility failed to ensure residents with a history of verbal altercations were free from mistreatment, resulting in a physical altercation causing injuries to both residents. Despite multiple verbal altercations and offers for room changes, the facility did not implement effective interventions to prevent escalation.

The visit was triggered by complaints #34241 and #33216. The allegations included staff abuse of Resident #1 and delayed emergency response for Resident #2. The complaint was substantiated with findings of noncompliance.

The investigation found failures to report alleged abuse within the required timeframe, delayed emergency medical service calls for a resident experiencing seizures, and inadequate nurse aide staffing levels. Multiple violations of Connecticut State Agencies regulations were identified.

The complaint involved an allegation that a nurse aide mocked a resident experiencing hallucinations and that the facility delayed reporting the abuse allegation to the State Agency. Additionally, a grievance was filed regarding the facility's delay in calling 911 for a resident having seizures despite physician orders and family requests. The complaint was substantiated with findings of delayed reporting and delayed emergency response.

The facility failed to report an allegation of staff-to-resident abuse to the State Agency within the required two-hour timeframe and failed to ensure emergency medical services were called in a timely manner after physician direction for a resident with seizures. Both deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.

The complaint investigation was triggered by allegations from Resident #1 of neglect due to being left in a soiled brief for an excessive amount of time without timely care, and from Resident #2 alleging abuse by a nurse. The investigation found substantiated neglect and failure to provide required staff education and assessments.

The facility failed to ensure timely care for an incontinent resident who was left in a soiled brief for approximately five hours, failed to provide required abuse education to staff, did not complete timely RN assessments after abuse allegations, and failed to maintain complete and accurate medical records including RN assessments of new bruises.

Complaint investigation was substantiated with violations found related to neglect and abuse involving Residents #1 and #2. Complaint numbers 34055 and 34078 were referenced.

Violations of Connecticut State regulations were identified related to neglect and abuse involving multiple residents. Deficiencies included failure to provide timely incontinent care, failure to educate staff on abuse policies, and failure to ensure timely RN assessments after allegations.

Complaint investigation was based on allegations of neglect and abuse involving Residents #1 and #2. The complaints included failure to provide timely care, physical abuse, and inadequate documentation. The complaints were substantiated with multiple violations found.

The facility was found to have multiple violations related to neglect and abuse of residents, including failure to provide timely incontinent care, failure to educate staff on abuse policies, failure to conduct timely RN assessments after allegations, and incomplete documentation of resident conditions. Plans of correction were submitted addressing these issues.

Complaint #32305, 32023. The complaint investigation was conducted to determine compliance with regulations following allegations of mistreatment and verbal abuse involving Resident #1.

The facility was found to have multiple violations including failure to notify the Resident Representative of an allegation of mistreatment, failure to ensure the resident was free from verbal abuse, failure to conduct annual performance evaluations for a Nurse Aide, failure to ensure yearly abuse prevention training for Nurse Aides, and failure to maintain nurse staffing according to the Public Health Code.

The visit was complaint-related triggered by concerns including failure to provide treatments as ordered, failure to offer hospice agency choice, infection control deficiencies during COVID-19 outbreak, lack of infection preventionist, and failure to notify responsible parties of COVID-19 infections.

Deficiencies were cited related to failure to provide treatments per physician orders, failure to offer hospice agency choice to resident's family, inadequate infection prevention and control practices including improper PPE use during a COVID-19 outbreak, lack of a designated Infection Preventionist, and failure to timely notify resident's responsible party of COVID-19 positive status.

Complaint investigation survey was conducted related to COVID-19 infection control and hospice care services. Multiple violations were substantiated including failure to notify families, incomplete documentation, and inadequate infection control practices.

The facility was found to have multiple violations including failure to timely notify families of COVID-19 positive residents, incomplete treatment documentation, failure to provide hospice service choices, inadequate use of PPE during a COVID-19 outbreak, and lack of a designated Infection Preventionist. Plans of correction were required with substantial compliance expected by July 1, 2022.

The report details multiple violations of Connecticut State Agencies regulations related to medication administration, abuse prevention, and medication storage. Specific deficiencies include failure to notify physicians of missed medication doses, failure to protect residents from misappropriation of property, failure to ensure pharmacy recommendations were timely acted upon, and failure to monitor medication refrigerator temperatures.

The complaint investigation included issues of missed medication doses for Resident #45, misappropriation of Resident #150's ring, failure to act on pharmacy recommendations for Resident #94, and improper medication storage temperatures affecting multiple residents.

The facility failed to notify the physician of missed medication doses for Resident #45, failed to protect Resident #150 from misappropriation of personal property, failed to act timely on pharmacy recommendations for Resident #94, and failed to maintain proper medication refrigerator temperatures for multiple residents' medications.

Complaint investigations #25440 and #26640 were reviewed during the inspection. Findings included substantiated medication errors and failure to protect residents from abuse and misappropriation of property.

The inspection identified violations related to medication administration errors, failure to protect residents from abuse and misappropriation of property, and failure to maintain proper medication refrigerator temperatures. Plans of correction were submitted with compliance dates of February 2, 2020.

Complaint #25611 was investigated. The allegation of abuse was substantiated, and Nursing Assistant #2 was terminated for violating the facility's abuse policy.

The investigation substantiated an allegation of abuse involving Resident #1 and Nursing Assistant #2. Resident #1 was found to have been handled roughly by staff, resulting in pain and distress. The facility failed to ensure the resident was free from abuse, and Nursing Assistant #2 was terminated. The facility's abuse policy was reviewed and found to prohibit mistreatment of residents.

The investigation was complaint-driven, focusing on allegations of abuse and improper care related to Resident #3 being tied to a wheelchair with a sheet, and other care deficiencies.

The facility was found deficient in multiple areas including failure to prevent abuse and improper use of restraints on Resident #3, failure to follow care plans and conduct neurological assessments after falls for Resident #2, failure to transfer Resident #1 according to plan of care resulting in injury, and failure to maintain complete and accurate medical records including undated physician orders.

The Plan of Correction addresses deficiencies related to restraint use, failure to ensure neurological assessments after falls, incomplete or inaccurate clinical records, and failure to ensure physician orders were dated when signed. The facility outlines corrective actions including staff re-education, audits, and monitoring to ensure compliance.

The complaint investigation found that the Ombudsman was not notified in writing of hospital admissions or transfers for Residents #51, #58, #64, and #81. Staff interviews confirmed lack of awareness of notification requirements and plans to correct this.

The facility failed to provide documentation that the Ombudsman was notified in writing of hospital admissions for four sampled residents. Interviews revealed staff were unaware of the notification requirement and had not been sending notifications, but planned to implement corrective actions going forward.

Violations of the Connecticut General Statutes and/or regulations were identified during the inspection. The facility failed to meet certain regulatory requirements including issues related to resident care, call bell response, restraint use, and facility maintenance.