Inspection Report Summary
The most recent inspection on March 27, 2025, identified deficiencies related to medication administration and admission procedures. Earlier inspections showed a pattern of deficiencies involving resident care issues such as medication omissions, inadequate follow-up care, pressure ulcer prevention, and failure to prevent resident-to-resident abuse. Several complaint investigations substantiated violations, including a fatal choking incident due to feeding supervision failures and multiple cases of resident abuse and neglect. Enforcement actions such as citations were issued in prior reports, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with clinical care and documentation, with no clear trend of sustained improvement in recent inspections.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
16.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
193% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
71% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #43324 and #43476.
Complaint Details
Complaint Investigation #43324 and #43476 were the basis for this inspection. Violations were substantiated as indicated by the attached violation letter.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as detailed in an attached violation letter dated 2025-04-11.
Report Facts
Licensed Bed Capacity: 120
Census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Szleszynski | Administrator | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 17, 2025
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on March 17, 26, and 27, 2025 by representatives of the Department of Public Health for the purpose of conducting multiple investigations related to complaints #43324 and #43476.
Complaint Details
The visit was complaint-related involving complaints #43324 and #43476. The complaints triggered investigations into medication administration and admission procedures.
Findings
The report identified violations including medication omissions for Resident #11 involving pregabalin doses missed on multiple occasions, and admission process failures for Resident #1 resulting in the resident not being admitted as expected. The facility failed to notify providers timely and document medication omissions properly.
Deficiencies (2)
Failure to administer pregabalin medication as ordered resulting in 24 missed doses over a 6-week period for Resident #11.
Failure to admit Resident #1 due to lack of hospital paperwork and communication breakdowns in the admissions process.
Report Facts
Missed medication doses: 24
Medication supply: 30
Medication supply: 12
Medication supply: 90
Audit period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction |
| Sylvia Szleszynski | Administrator | Facility administrator named in correspondence and responsible for submitting plan of correction |
| MD #1 | Medical doctor involved in treatment and interview regarding Resident #11's medication | |
| APRN #1 | Advanced Practice Registered Nurse who prescribed pregabalin for Resident #11 | |
| Pharmacist #1 | Pharmacist interviewed regarding pregabalin prescription and supply issues | |
| RN #1 | Registered Nurse | Nursing supervisor on 3/1/25 involved in admission process for Resident #1 |
| Regional Director of Nursing | Interviewed regarding admission incident for Resident #1 | |
| Medical Director | Interviewed regarding notification expectations for admissions | |
| Admissions Coordinator | Interviewed regarding admissions process and communication failures | |
| DNS | Director of Nursing Services | Responsible for monitoring compliance with plan of correction and involved in interviews |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 120
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #42427 and #42511.
Complaint Details
Complaint Investigation #42427 and #42511 were the basis for the visit. Violations were substantiated as violations were identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter dated 2025-02-05.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Szleszynski | Administrator | Personnel contacted during the inspection. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 14, 2025
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on January 14 and 17, 2025 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations related to complaints #42427 and #42511.
Complaint Details
The visit was complaint-related involving complaints #42427 and #42511. The complaints involved issues with follow-up care, skin integrity, resident supervision, and reporting of incidents. Substantiation status is not explicitly stated.
Findings
The report details multiple violations related to inadequate follow-up care for residents with fractures, failure to inspect skin under splints leading to pressure ulcers, failure to ensure residents were not left unattended while ambulating, and failure to report falls with injuries to the State Agency. The facility submitted plans of correction addressing these issues with timelines and monitoring responsibilities.
Deficiencies (4)
Failure to ensure timely orthopedic follow-up for Resident #2 after a fall with fracture.
Failure to inspect residents' skin under splints resulting in a pressure ulcer for Resident #2.
Failure to ensure Resident #1 was not left unattended while ambulating, resulting in a fall and injury.
Failure to report a fall with fracture to the State Agency as required for Resident #2.
Report Facts
Days delay in orthopedic follow-up: 61
Pressure ulcer size: 3.5
Pressure ulcer size: 0.5
Fall risk score: 6
Number of falls: 2
Audit period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding the plan of correction submission. |
| Sylvia Szleszynski | Administrator | Administrator of Apple Rehab Rocky Hill, named in the notice letter. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 120
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
The inspection visit was conducted to review complaint investigations #42089 and #42138.
Complaint Details
Complaint investigations #42089 and #42138 were reviewed and found to have no violations.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Szleszynski | Administrator | Personnel contacted during the inspection. |
| Lisa Palmer | DON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Renewal
Census: 87
Capacity: 120
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection for the facility.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. See attached violation letter for details.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sylvia Szleszynski | Administrator | Personnel contacted during the inspection |
| Lisa Palmer | CONNS | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 120
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation referenced by complaint #38244.
Complaint Details
Complaint investigation #38244 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katerina Zhao | Administrator | Personnel contacted during the inspection. |
| Lisa Palmer | DNS | Personnel contacted during the inspection. |
Inspection Report
Follow-Up
Census: 92
Capacity: 120
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The visit was conducted for the purpose of reviewing the plan of corrections for the letter dated 1/9/24.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Palmer | DNS | Personnel contacted during the inspection |
| Cynthia Hayle | RN | Report submitted by |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 120
Deficiencies: 4
Date: Dec 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint Investigation #34441 and #36643, with violations identified and a citation issued as a result of the inspection.
Complaint Details
The complaint investigation involved allegations of resident-to-resident physical abuse which was substantiated. The investigation included clinical record reviews, interviews, and facility documentation. Resident #1 was found to have physically abused Residents #2, #3, and #4. The facility was cited for failure to prevent abuse and for deficiencies in care planning and documentation.
Findings
The inspection found violations related to resident-to-resident abuse, failure to complete Minimum Data Set (MDS) assessments timely, and inadequate nursing documentation and observation practices. The resident abuse was substantiated, and multiple deficiencies were cited with plans of correction required.
Deficiencies (4)
Failure to ensure Residents #2, #3, and #4 were free from physical abuse by Resident #1, including incidents of punching and hitting.
Failure to complete Minimum Data Set (MDS) assessments within the regulatory timeframe for 30 of 34 residents.
Resident #5 sustained an acute fracture of the proximal humerus after being hit by a meal cart; failure to prevent injury and remove hazardous equipment.
Failure to provide proper nursing documentation and 1:1 observation documentation for Resident #1 after an incident requiring observation.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 83
Complaint Investigations: 2
Residents Reviewed for Abuse Allegation: 4
Residents Reviewed for MDS Deficiency: 30
Residents Total: 34
Plan of Correction Compliance Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katerina Zhao | Administrator | Named as facility administrator during inspection and in correspondence. |
| Lisa Palmer | DNS | Director of Nursing Services contacted during inspection. |
| Melissa Cope | Director of Clinical Services | Named as personnel contacted during inspection. |
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letter related to the inspection findings. |
| Connie Vumback | RN NC | Facility Licensing and Investigations Section staff who signed the inspection report. |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 120
Deficiencies: 4
Date: Dec 7, 2023
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on December 7 and 8, 2023, to conduct multiple investigations related to complaints #34441 and #36643.
Complaint Details
Complaint investigation numbers #34441 and #36643 were substantiated, including resident-to-resident abuse and other regulatory violations.
Findings
Violations of the General Statutes of Connecticut and regulations were identified, including substantiated resident-to-resident abuse, failure to complete Minimum Data Set (MDS) assessments timely, failure to prevent resident injury from accidents, and inadequate nursing documentation and observation. A citation (#2024-04) was issued as a result.
Deficiencies (4)
Failure to ensure residents #2, #3, and #4 were free from physical abuse by Resident #1.
Failure to complete Minimum Data Set (MDS) assessments within the regulatory timeframe for 30 of 34 residents reviewed.
Failure to ensure Resident #5 was not struck by a meal cart causing a fracture of the right humerus.
Failure to provide adequate 1:1 observation documentation and nursing documentation for Resident #1 after an abuse incident.
Report Facts
Census: 83
Total Capacity: 120
Number of residents reviewed for MDS assessments: 30
Number of residents reviewed for accidents: 1
Number of residents reviewed for abuse allegation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katerina Zhao | Administrator | Personnel contacted during inspection |
| Lisa Palmer | DNS | Personnel contacted during inspection |
| Melissa Cope | Director of Clinical Services | Personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding violations and plan of correction |
| RN #3 | Registered Nurse | Involved in observations and findings related to abuse and medication pass |
| RN #5 | Registered Nurse (previous Director of Nursing) | Involved in resident-to-resident abuse investigation |
| Director of Nursing | Interviewed regarding 1:1 observation and abuse incidents | |
| Dietary Aide #1 | Identified in accident involving Resident #5 and meal cart | |
| Food Service Director | Interviewed regarding meal cart incident | |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding late MDS assessments |
| RN #4 | Registered Nurse | Interviewed regarding MDS assessments and facility guidelines |
| Advanced Practice Registered Nurse (APRN) | Provided assessment related to Resident #1's condition |
Inspection Report
Follow-Up
Census: 73
Capacity: 120
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
A desk audit was completed to review the plan of correction for a prior violation letter dated 2/8/23, and a follow-up phone notification was made to confirm all violations were corrected.
Findings
The inspection found that all previously identified violations were corrected as confirmed by the administrator during a telephone notification on the date of the desk audit.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katerina Zhao | Administrator | Notified via telephone that all violations were corrected |
| Melissa Talamini | NC | Report submitted by |
Inspection Report
Renewal
Census: 71
Capacity: 120
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
A desk audit was completed on 4/6/23 to renew the plan of correction for the violation letter dated 1/1/23.
Findings
The administrator was notified via telephone that all violations were corrected as of 4/6/23 at 2:09 PM.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Talamini | NC | Report submitted by and signed on the licensing inspection report. |
| Katerina Zhao | Personnel contacted and administrator notified of correction of violations. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 2
Date: Jan 23, 2023
Visit Reason
An unannounced visit was made to Apple Rehab Rocky Hill on January 23, 2023, for the purpose of conducting a complaint investigation (#33686).
Complaint Details
Complaint Investigation #33686. The allegation of mistreatment was not substantiated, but deficiencies were found related to care plan revision and employee evaluations.
Findings
The investigation found that the facility failed to revise the care plan for a resident with accusatory behavior and failed to ensure yearly performance evaluations for nurse aides were completed. Plans of correction were submitted to address these issues.
Deficiencies (2)
Failure to revise the care plan to address how to care for a resident with accusatory behavior.
Failure to ensure yearly performance evaluations were completed for nurse aides.
Report Facts
Licensed Bed Capacity: 120
Census: 68
Complaint Number: 33686
Dates: Jan 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Brown | Administrator | Named in relation to the complaint investigation and findings. |
| Marline Santer | Director of Nursing | Named as personnel contacted and responsible for ensuring evaluations were completed. |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding the complaint investigation. |
Inspection Report
Monitoring
Census: 66
Capacity: 120
Deficiencies: 0
Date: Jun 27, 2022
Visit Reason
A desk audit review was conducted to review the plan of correction for the violation letter dated 5/11/22 and to verify correction of previously identified violations 1a and 2a.
Findings
No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this desk audit inspection, indicating that the previously cited violations have been corrected.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Banton | RN, DNS | Personnel contacted during inspection |
| Kibby Phillips | Generalist Surveyor, HPA | Surveyor conducting the inspection and report submission |
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 2
Date: Apr 29, 2022
Visit Reason
Unannounced visits were conducted to Apple Rehab Rocky Hill to perform a Recertification Survey to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with additional information received through April 29, 2022.
Findings
Two violations were identified: 1) Failure to ensure CPAP masks were stored according to facility policy and infection control, and 2) Inadequate policies and procedures to address continuity of care during an internet service outage/disruption affecting medication administration for 16 of 61 residents.
Deficiencies (2)
Facility failed to ensure CPAP masks were stored in accordance with facility policy and infection control.
Facility failed to have adequate policies and procedures to address continuity of care during an internet service outage/disruption, including medication administration documentation.
Report Facts
Residents affected: 16
Residents reviewed: 61
Residents listed: 16
Audit duration: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the letter and referenced as contact for questions |
| Keith Brown | Administrator | Facility administrator addressed in the letter and involved in interview regarding internet outage |
| RN #1 | Interviewed regarding CPAP policy and medication administration during internet outage | |
| LPN #2 | Interviewed regarding inability to access electronic MAR during internet outage | |
| DNS | Director of Nursing Services interviewed regarding medication administration and audits |
Inspection Report
Renewal
Census: 61
Capacity: 120
Deficiencies: 0
Date: Apr 26, 2022
Visit Reason
An unannounced visit was made to the facility on 04/26, 04/27, 04/28, and 04/29/2022 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a certification survey and a licensure inspection.
Findings
Staffing was reviewed from 04/10/22 to 05/04/22 and found to meet the requirements of the Public Health Code. Deficiencies were identified during this certification survey.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Brown | Administrator | Personnel contacted during inspection |
| Bernadette Banton | DNS | Personnel contacted during inspection |
| Nicholas Tomczyk | Nurse Consultant | Author of the narrative report and report submitter |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 120
Deficiencies: 1
Date: Mar 3, 2022
Visit Reason
An unannounced visit was made to Apple Rehab Rocky Hill on 3/3/22 for the purpose of conducting a complaint investigation and a Covid-19 vaccination survey.
Complaint Details
Complaint Investigation CT# 31761 was conducted. The complaint was substantiated as violations were identified related to feeding supervision and care for Resident #1, who subsequently died after a choking incident.
Findings
The facility was found to have violations related to failure to ensure family members assisting Resident #1 with feeding were provided with feeding strategies/recommendations and ongoing evaluation of feeding techniques. Resident #1 experienced a fatal choking incident due to lack of supervision and failure to follow feeding protocols.
Deficiencies (1)
Failure to ensure all family members who assisted Resident #1 with meals were provided with feeding strategies/recommendations and ongoing evaluation of feeding techniques.
Report Facts
Census: 61
Total Capacity: 120
Complaint Number: 31761
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ellen Valentin | RN, NC | Facility Licensing & Investigations Section representative conducting the inspection |
| Judith Birtwistle | Supervising Nurse Consultant | Signed the violation letter and notice of noncompliance |
| Keith Brown | Administrator | Facility administrator addressed in the violation letter |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 3, 2022
Visit Reason
A Covid-19 Vaccination survey and Complaint Investigation was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Complaint Details
The complaint investigation focused on Resident #1 who required supervision during meals due to severe dysphagia. The facility failed to provide feeding strategy education and supervision to family members assisting Resident #1, leading to a choking incident and Resident #1's death. The complaint was substantiated by clinical record review, interviews, and facility documentation.
Findings
The facility failed to ensure that all family members assisting Resident #1 with meals were provided feeding strategies and ongoing evaluation as per Speech Pathologist and Resident Care Plan interventions. Resident #1, who had severe dysphagia and required supervision during meals, was not properly supervised or assisted by trained family members, resulting in a fatal choking incident.
Deficiencies (1)
Failure to ensure all family members assisting Resident #1 with meals were provided feeding strategies/recommendations and ongoing evaluation as per Speech Pathologist and Resident Care Plan interventions.
Report Facts
Date of survey: Mar 3, 2022
Plan of Correction Completion Date: May 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Identified responsibility to include physician's orders for feeding into care plan and NA care card |
| Speech Pathologist #1 | Speech Pathologist | Provided feeding strategies to only one family member and expected nursing staff to educate and evaluate family members feeding Resident #1 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed choking incident and assisted with Heimlich maneuver; identified family members supervised Resident #1 during meals without staff supervision or competency assessment |
| Nurse Aide #1 | Nurse Aide | Observed feeding by family member, instructed to slow down feeding but did not supervise continuously |
| Nurse Aide #2 | Nurse Aide | Identified family members fed Resident #1 instead of staff and did not supervise meals |
| Director of Nursing Services | DNS | Responsible for Plan of Correction and acknowledged staff should supervise feeding or evaluate family member competency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 9, 2022
Visit Reason
The inspection was conducted as a desk audit review for a complaint investigation identified by complaint numbers CT 30106, 29940, and 30623.
Complaint Details
Complaint investigation referenced by complaint numbers CT 30106, 29940, and 30623. The review concluded that all violations were corrected.
Findings
The desk audit review found that all violations cited in the previous violation letter dated 12-3-2021 have been corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Rosato | RN NC | Signed the licensing inspection narrative report confirming the desk audit review findings. |
Inspection Report
Renewal
Census: 57
Capacity: 120
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection and included review of complaint investigations numbered CT#29940, CT#30207, CT#30623, and CT#30106.
Complaint Details
Complaint investigations referenced by numbers CT#29940, CT#30207, CT#30623, and CT#30106 were reviewed as part of the inspection.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were not identified at the time of this inspection. Certification files were reviewed and approval for issuance of license was granted.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Brown | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 120
Deficiencies: 9
Date: May 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaints regarding alleged mistreatment, neglect, and inadequate care of residents at Apple Rehab Rocky Hill.
Complaint Details
The complaint investigation was substantiated with findings of mistreatment, neglect, and failure to provide adequate care to residents. Multiple complaints were reviewed, including allegations of physical abuse, neglect in incontinent care, failure to prevent falls, and inadequate supervision. The facility was found responsible for these violations.
Findings
The investigation substantiated several allegations of resident abuse, neglect, and failure to provide adequate care, including improper handling of incontinent residents, failure to prevent falls, inadequate supervision, and medication administration issues. Multiple violations of Connecticut State Agencies regulations were identified.
Deficiencies (9)
Failure to provide adequate care and supervision to Resident #5, including neglect in toileting and incontinent care.
Failure to investigate and address allegations of abuse and mistreatment involving multiple residents.
Failure to maintain a clean, comfortable, and home-like environment, including issues with room maintenance and safety hazards.
Failure to ensure timely and accurate documentation and review of clinical records, including advanced directives and care plans.
Failure to ensure staff were properly trained and certified, including CPR certification and IV therapy competency.
Failure to ensure proper medication storage, labeling, and administration, including expired medications and improper handling.
Failure to ensure adequate supervision and care to prevent resident falls and injuries.
Failure to ensure adequate staffing and performance evaluations for nursing aides.
Failure to ensure proper dietary services, including food texture and quality during meals.
Report Facts
Licensed Bed Capacity: 120
Census: 64
Inspection Dates: 2021-04-05 to 2021-04-15
Plan of Correction Compliance Date: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Brown | Administrator | Named in multiple findings related to facility administration and oversight. |
| Kenitra Sherman | Director of Nursing | Named in relation to complaint investigation and findings. |
| Corey Cheyne | Administrator | Named in inspection and complaint investigation. |
| Karen Gworek | Supervising Nurse Consultant | Author of important notice regarding noncompliance and plan of correction. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed official correspondence related to complaint investigations. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 17, 2021
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on May 17 and 20, 2021 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations related to complaints.
Complaint Details
Complaints #26648, #27242, #27344, and #30117 were investigated. Staff to resident abuse was substantiated in the case of Resident #3. Neglect allegations related to Resident #5 were also substantiated. Psychosocial support failures and care plan deficiencies were identified.
Findings
The investigation identified multiple violations including failure to prevent physical abuse and neglect of residents, failure to report allegations of neglect timely, failure to review and revise care plans after witnessed incidents, and failure to provide psychosocial support after incidents. Staff abuse was substantiated in one case and inadequate care and documentation were noted in others.
Deficiencies (6)
Failure to ensure Resident #3 was free from physical abuse and failure to provide timely incontinence care to Resident #5.
Failure to report allegations of neglect to the Administrator or State Agency timely.
Failure to review and revise the plan of care to address a witnessed physical incident between a staff member and Resident #3.
Failure to develop a comprehensive care plan for Resident #1 requiring assistance with personal hygiene and oral care.
Failure to provide psychosocial support to Resident #3 after a witnessed physical altercation.
Failure to ensure clinical record was complete and accurate regarding a witnessed physical altercation involving Resident #3.
Report Facts
Complaints investigated: 4
Plan of correction submission deadline: Jun 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding the inspection and violations |
| Keith Brown | Administrator | Facility administrator addressed in the notice letter |
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Apr 15, 2021
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on April 15, 2021, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations, a licensure and certification inspection.
Findings
The report details multiple violations of the Regulations of Connecticut State Agencies related to clinical records, facility policy, resident care, medication administration, abuse investigations, environmental conditions, infection control, and staff certifications. The facility failed to ensure compliance in areas such as advanced directives, maintaining a clean environment, abuse policy implementation, medication management, fall prevention, immunizations, and water management to mitigate Legionella risk.
Deficiencies (19)
Failure to ensure advance directives were addressed for residents.
Facility failed to maintain a clean, comfortable, and homelike environment.
Failure to initiate and respond to grievances related to staff interaction and abuse allegations.
Failure to implement policies regarding abuse allegations.
Failure to thoroughly investigate the origin of a resident's fracture.
Failure to follow the Resident Care Plan for incontinent checks on the night shift.
Failure to obtain and follow up on urine culture and sensitivity results.
Failure to ensure wound treatment was completed in accordance with physician orders.
Failure to ensure nursing staff were educated and audits conducted to prevent falls and ensure proper toileting interventions.
Failure to ensure licensed nursing staff were certified in IV therapy prior to administering IV hydration.
Failure to ensure dialysis access site was monitored for bruit/thrill and emergency supplies were available.
Failure to ensure sufficient nursing staff were certified in CPR.
Failure to ensure timely performance evaluations for nurse aides.
Failure to ensure medications were removed after expiration and not administered after expiration.
Failure to ensure food served had appropriate texture and consistency.
Failure to implement dietary department infection control methods.
Failure to ensure effective administration to utilize resources for physical, mental, and psychosocial well-being of residents.
Failure to implement an effective water management plan to mitigate Legionella risk.
Failure to ensure pneumococcal and Prevnar 13 vaccines were offered and administered according to guidelines.
Report Facts
Residents reviewed: 16
Plan of correction submission deadline: 2021
Compliance deadlines: 2021
Fall risk score: 16
Fall risk score: 17
Water sample positive counts: 3
Licensed nursing staff: 30
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed the initial notice letter to the facility administrator. |
| Cory Cheyne | Administrator | Facility administrator addressed in the notice and responsible for oversight of plan of correction. |
| RN #1 | Nurse | Involved in multiple resident care and abuse investigation findings. |
| RN #5 | Nurse | Interviewed regarding abuse incident and staff notification. |
| RN #6 | Nurse | Involved in resident care, abuse investigations, and medication administration reviews. |
| RN #7 | Nurse | Interviewed regarding resident incidents and medication administration. |
| RN #8 | Nurse | Involved in resident care, abuse investigations, and medication administration reviews. |
| RN #9 | Nurse | Failed to provide care to resident during shift. |
| RN #10 | Nurse | Involved in abuse investigation and resident care. |
| LPN #4 | Licensed Practical Nurse | Involved in medication administration and resident care. |
| LPN #6 | Licensed Practical Nurse | Involved in resident care and abuse incident. |
| LPN #7 | Licensed Practical Nurse | Involved in resident care and abuse incident. |
| LPN #8 | Licensed Practical Nurse | Involved in resident care and abuse incident. |
| Corporate Nurse #1 | Nurse | Conducted investigations and interviews related to resident care and abuse. |
| Social Worker #1 | Social Worker | Responsible for grievance/concern log and interviews. |
| Director of Nursing | Director of Nursing | Interviewed regarding resident care and abuse investigations. |
| Director of Maintenance | Director of Maintenance | Interviewed regarding facility maintenance and water management. |
| Facility Infection Control Nurse (ICN) | Infection Control Nurse | Responsible for educating nursing staff on water use and infection control. |
| Regional Clinical RN #1 | Regional Clinical Registered Nurse | Interviewed regarding CPR certification and infection control. |
| Regional Clinical RN #2 | Regional Clinical Registered Nurse | Interviewed regarding CPR certification and infection control. |
| Director of Rehabilitation/Physical Therapist | Physical Therapist | Interviewed regarding resident mobility and care. |
| Dietary Aide #1 | Dietary Aide | Interviewed regarding food service and infection control. |
| Dietary Aide #2 | Dietary Aide | Interviewed regarding food service and infection control. |
| Dietary Aide #3 | Dietary Aide | Interviewed regarding food service and infection control. |
Inspection Report
Routine
Census: 63
Capacity: 120
Deficiencies: 18
Date: Jun 15, 2020
Visit Reason
The inspection was conducted as a COVID-19 Infection Control Survey to assess compliance with infection control protocols during the pandemic.
Findings
Violations of Connecticut State regulations were identified during the COVID-19 Infection Control Survey, with deficiencies related to infection prevention and control practices. A plan of correction was required to address these issues.
Deficiencies (18)
Failure to ensure Covid-19 infection prevention protocols were consistently implemented, including improper use and storage of disposable PPE gowns by therapy staff.
Failure to provide timely access to medical records and delays in responding to medical record requests.
Failure to ensure adequate water pressure and hot water temperature in resident bathrooms.
Failure to report and investigate an allegation of resident abuse in a timely and appropriate manner.
Failure to ensure nursing staff competencies and skills were maintained and documented.
Failure to ensure proper medication administration and documentation, including missed insulin doses and delayed pain medication.
Failure to ensure residents were properly positioned for feeding and to provide adequate assistance during meals.
Failure to ensure a hazard-free environment related to medication and treatment solutions left unsecured at the bedside.
Failure to ensure dental services were provided timely to residents.
Failure to ensure infection control signage was posted and personal care supplies were stored according to infection control standards.
Failure to ensure sufficient nursing staff to meet resident needs.
Failure to ensure nursing staff competencies and skills were maintained and documented.
Failure to ensure proper use and discontinuation of psychotropic medications.
Failure to ensure facility assessment addressed security of electronic keypads and ongoing documentation for residents on the lower level unit.
Failure to ensure infection control practices related to isolation precautions and multi-drug resistant organisms were followed.
Failure to ensure proper infection prevention and control practices in laundry and housekeeping, including PPE use and water temperature monitoring.
Failure to ensure pneumococcal vaccination tracking and administration according to CDC guidelines.
Failure to ensure pain management was provided timely and adequately to residents.
Report Facts
Licensed Bed Capacity: 120
Census: 63
Plan of Correction Submission Deadline: 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Hackett | DNS | Personnel contacted during the inspection on 2020-06-15. |
| Cara Urban | RN, BSN | Report submitted by Cara Urban, RN, BSN, NC on 2020-05-13. |
| Cory Cheyne | Administrator | Administrator named in multiple inspection reports and notices. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed important notices related to noncompliance and plans of correction. |
| Maura Murray | Corporate Nurse | Personnel contacted during the inspection on 2020-05-13. |
Inspection Report
Abbreviated Survey
Census: 68
Capacity: 120
Deficiencies: 1
Date: May 31, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility had implemented CMS and CDC recommended practices related to COVID-19; however, deficiencies were cited due to failure to ensure appropriate infection control practices, specifically visitor screening procedures were not consistently followed upon entry.
Deficiencies (1)
Failure to ensure appropriate infection control practices to prevent and control the spread of infection, including inconsistent visitor temperature screening and symptom questionnaire completion upon entry.
Report Facts
Capacity: 120
Census: 68
Time delay: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Opened the facility door for the surveyor and did not perform visitor screening initially | |
| Nursing Supervisor | Greeted surveyor, was responsible for visitor screening during off shifts and weekends, but was occupied during survey | |
| Infection Control Nurse | Provided information about facility policy on visitor screening |
Inspection Report
Abbreviated Survey
Census: 69
Capacity: 120
Deficiencies: 0
Date: May 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities, focusing on CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with infection prevention and control practices related to COVID-19. No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 13, 2020
Visit Reason
An unannounced visit was conducted on May 13, 2020 by the Department of Public Health for the purpose of conducting an investigation and a COVID-19 Infection Control Monitoring Survey.
Complaint Details
Complaint #27430 triggered the investigation.
Findings
The report identified violations of Connecticut State regulations related to medical record requests, notification of changes in resident condition, and inconsistent implementation of COVID-19 infection prevention protocols, including improper handling of disposable PPE by therapy staff.
Deficiencies (3)
Failure to provide requested medical records within regulatory timeframes and failure to notify resident's representative of changes in condition.
Failure to consistently implement COVID-19 infection prevention protocols, including improper reuse and transport of disposable PPE gowns by therapy staff.
Facility policy and practice did not ensure timely notification of responsible parties regarding resident condition changes.
Report Facts
Days delay in medical record invoice: 23
Resident admission date: Jun 4, 2019
Resident temperature: 101.1
Plan of correction submission deadline: Jun 6, 2020
Substantial compliance target date: Jun 19, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed letter directing plan of correction submission. |
| Person #2 | Resident's representative who requested medical records and was involved in notification issues. | |
| RN #4 | Corporate Interim DNS | Identified issues with notification of resident condition changes. |
| LPN #1 | Licensed Practical Nurse | Documented resident symptoms and notification practices. |
| RN #5 | Corporate Nurse | Provided information on medical record request timeframes. |
| PT #1 | Physical Therapist | Observed removing and reusing disposable PPE gowns improperly. |
| OT #1 | Occupational Therapist | Observed wearing and handling disposable PPE gowns inconsistently with policy. |
Inspection Report
Abbreviated Survey
Census: 72
Capacity: 120
Deficiencies: 0
Date: May 6, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility implemented CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 120
Census: 72
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 30, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 30, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 27, 2020
Visit Reason
An unannounced visit was conducted on April 27, 2020, by the Department of Public Health for the purpose of conducting an investigation and a COVID-19 Focused Survey at Apple Rehab Rocky Hill.
Complaint Details
The visit was triggered by a complaint or investigation related to COVID-19 infection control practices. The report does not explicitly state substantiation status.
Findings
The inspection identified multiple infection control deficiencies related to COVID-19 precautions, including failure to keep isolation room doors closed, improper placement and disposal of PPE, lack of staff knowledge on PPE protocols, and inadequate cleaning and cohorting practices. The facility was found noncompliant with state regulations and CDC guidelines.
Deficiencies (5)
Doors of COVID-19 positive residents' rooms were not kept closed as required by CDC guidelines.
PPE disposal bins were improperly located outside resident rooms and mixed clean and dirty PPE disposal bins were found inappropriately placed.
Staff lacked knowledge regarding PPE disposal procedures and isolation precautions.
Resident rooms were not properly cleaned or marked as cleaned, and cohorting of COVID-19 positive and negative residents was not properly managed.
Laundry aide did not follow proper infection control practices including glove changes and hand hygiene between rooms.
Report Facts
Date of inspection: Apr 27, 2020
Plan of correction submission deadline: May 15, 2020
Substantial compliance deadline: May 29, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Author of the notice letter |
| Cory Cheyne | Administrator | Facility administrator addressed in the letter and interviewed during inspection |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding door closure and PPE disposal procedures |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding gown reuse and isolation precautions |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding gown removal procedures |
| Corporate Nurse | Corporate Nurse | Interviewed regarding PPE disposal practices |
| Corporate Registered Nurse #2 | Corporate Registered Nurse | Interviewed regarding PPE storage process |
| Laundry Aide #1 | Laundry Aide | Observed and interviewed regarding infection control practices |
| Director of Housekeeping | Director of Housekeeping | Interviewed regarding cleaning procedures and laundry delivery |
| Administrator | Administrator | Interviewed regarding staff PPE comfort and ancillary staff access |
| Director of Nursing Services (DNS) | Director of Nursing Services | Interviewed regarding resident cohorting and audits |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding resident cohorting and COVID-19 status communication |
| Infection Preventionist | Infection Preventionist | Interviewed regarding daily COVID-19 status updates and facility map |
| Nurse Aides #1 and #2 | Nurse Aides | Interviewed regarding isolation precautions for Resident #18 |
Inspection Report
Monitoring
Deficiencies: 7
Date: Apr 27, 2020
Visit Reason
A COVID-19 Monitoring Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
The facility failed to consistently implement COVID-19 infection prevention protocols, including keeping COVID-positive resident room doors closed, proper placement and use of PPE disposal bins, reuse of isolation suits without proper policy, incorrect signage on resident rooms, improper laundry handling practices, and failure to timely cohort COVID-positive and negative residents.
Deficiencies (7)
Failure to keep bedroom doors closed for COVID-positive residents as per CDC guidelines.
Improper placement of PPE disposal bins outside resident rooms instead of inside.
Reuse of isolation suits without a facility policy and improper PPE gown coverage of arms.
Droplet precaution signage left on COVID-negative resident's room.
Laundry aide failed to change gloves and wash hands between rooms and lacked process for delivering laundry to COVID-positive and negative rooms.
Unoccupied resident room door left open and beds unmade without signage indicating cleaning completion.
Failure to timely cohort COVID-positive and negative roommates and offer room changes appropriately.
Report Facts
Date of survey: Apr 27, 2020
Number of rooms with droplet precaution signs and open doors: 26
Date of lab results: Apr 23, 2020
Resident admission dates: Oct 4, 2016
Resident admission dates: Feb 21, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding open doors and PPE bin placement; closed doors after observation |
| Licensed Practical Nurse #2 | LPN | Observed wearing hospital gown over isolation suit with exposed arms; described reuse of suit |
| Licensed Practical Nurse #3 | LPN | Interviewed about PPE removal practices |
| Corporate Nurse | Nurse | Provided guidance on PPE disposal cart placement and reuse policy |
| Corporate Registered Nurse #2 | RN | Identified process to store reusable PPE in facility |
| Director of Housekeeping | DOH | Interviewed about laundry and housekeeping practices |
| Laundry Aide #1 | LA | Observed improper glove use and laundry delivery practices |
| Administrator | Administrator | Interviewed about PPE ownership and ancillary staff entering COVID-positive rooms |
| Infection Preventionist | Infection Preventionist | Described COVID-19 status tracking and communication |
| Registered Nurse #1 | RN | Interviewed about cohorting COVID-positive and negative residents |
| Director of Nursing Services | DNS | Interviewed about cohorting and communication of COVID status |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 14, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Complaint Investigation
Census: 88
Capacity: 120
Deficiencies: 3
Date: Mar 16, 2020
Visit Reason
An unannounced visit was made to Apple Rehab Rocky Hill on March 16, 2020, as part of a complaint investigation (Complaint #27098) by the Facility Licensing and Investigations Section of the Department of Public Health.
Complaint Details
Complaint #27098 triggered the investigation. The complaint involved concerns about resident safety, psychosocial support, and elopement risks. The complaint was substantiated as violations were identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of inspection. The findings included failure to ensure psychosocial support for a resident after receiving a new roommate, inadequate monitoring and management of resident behaviors, and failure to ensure proper care and safety measures for residents exhibiting behavioral disturbances and elopement risks.
Deficiencies (3)
Failure to ensure psychosocial support was provided to a resident after receiving a new roommate.
Failure to conduct daily door checks in accordance with facility policy, resulting in incomplete monitoring of wander guard devices and doors.
Failure to ensure that a resident on a secured dementia unit did not exit the unit and facility unattended.
Report Facts
Licensed Bed/Bassinet Capacity: 120
Census: 88
Plan of Correction Submission Deadline: 2020
Frequency of Audits: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Cope | Acting Director of Nursing | Named in interview and clinical record review related to resident behavior management. |
| Cory Cheyne | Administrator | Named as facility administrator and involved in interviews regarding findings. |
| Karen Gworek | Supervising Nurse Consultant | Signed the important notice letter related to the complaint investigation. |
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Feb 6, 2020
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill which concluded on February 6, 2020 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation, and a certification inspection.
Findings
The report details multiple violations of Connecticut State Agencies regulations including failure to provide care in a dignified manner, failure to ensure resident preferences, inadequate water pressure and temperature, environmental deficiencies, failure to report allegations of abuse, medication administration errors, insufficient staffing, infection control issues, and failure to ensure resident safety and quality care.
Deficiencies (15)
Facility failed to provide care in a dignified manner to Resident #14 including abuse/neglect by nurse aide.
Facility failed to ensure Resident #27's accommodation needs and call bell functioning.
Facility failed to ensure adequate water pressure and hot water temperatures in resident bathrooms and maintain a clean environment.
Facility failed to report an allegation of abuse regarding Resident #14.
Facility nursing staff failed to properly administer medications and treatments to multiple residents.
Facility failed to ensure proper feeding and positioning for dependent residents.
Facility failed to follow physician's orders regarding medications for multiple residents.
Facility failed to ensure sufficient nursing staff to meet resident needs.
Facility failed to ensure hazard free environment by securing medications and treatment solutions at bedside.
Facility failed to administer pain medication as needed upon resident request.
Facility failed to ensure nursing staff competencies and skills necessary to care for resident needs.
Facility failed to ensure stop or discontinue dates were included with use of PRN psychotropic medications.
Facility failed to ensure timely dental services for residents.
Facility failed to ensure infection control practices including posting isolation signs and tracking multi-drug resistant organisms.
Facility failed to ensure pneumococcal vaccination administration and tracking per CDC guidelines.
Report Facts
Compliance date: 2020
Staff turnover rate: 35.9
New hires and terminations: 71
Resident counts: 24
Resident counts: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed the initial notice letter regarding the inspection and plan of correction. |
| Cory Cheyne | Administrator | Administrator of Apple Rehab Rocky Hill named in the report. |
| RN #1 | Registered Nurse | Named in multiple findings related to medication administration, infection control, and staff competencies. |
| RN #3 | Registered Nurse | Involved in investigative reports and resident care observations. |
| LPN #3 | Licensed Practical Nurse | Named in medication administration and resident care findings. |
| LPN #4 | Licensed Practical Nurse | Named in resident care and medication administration findings. |
| Director of Maintenance | Interviewed regarding water pressure and maintenance issues. | |
| Housekeeping Director | Interviewed regarding housekeeping and environmental concerns. | |
| Pharmacy Consultant #1 | Interviewed regarding medication administration and psychotropic drug use. | |
| Pharmacy Consultant #2 | Interviewed regarding medication administration and psychotropic drug use. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 19, 2019
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on November 19, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
Complaint numbers #26467 and #26297 are referenced, indicating the visit was related to complaint investigations.
Findings
The report details violations related to failure to ensure proper 15-minute checks for residents at risk for elopement, inadequate monitoring of wander guard devices, failure to conduct daily door checks, and insufficient interventions to prevent resident elopements. The facility submitted a plan of correction addressing these issues.
Deficiencies (3)
Failure to ensure that residents at risk for elopement had every fifteen minute checks completed and that wander guard devices were monitored in accordance with facility policy.
Failure to ensure that a resident on a secured dementia unit did not exit the unit unattended and that exit doors were checked daily for function.
Failure to conduct daily door checks in accordance with facility policy, including checking keypads, alarmed doors, and wander guard system functioning.
Report Facts
Date of inspection visit: Nov 19, 2019
Plan of correction submission deadline: Dec 12, 2019
Frequency of resident checks: 15
Number of residents reviewed for elopement risk: 6
Number of days door checks were not completed: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Newton | Supervising Nurse Consultant | Signed the letter and referenced in relation to the plan of correction instructions. |
| Cory Cheyne | Administrator | Administrator of Apple Rehab Rocky Hill, recipient of the report. |
| Director of Nursing | Interviewed regarding resident monitoring and elopement policies. | |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Mentioned in relation to resident elopement incident and door security. |
| Nurse Aide (NA) #1 | Nurse Aide | Mentioned in relation to following resident and elopement incident. |
| Housekeeping Aide (HA) #1 | Housekeeping Aide | Mentioned in relation to resident elopement incident. |
| Registered Nurse (RN) #1 | Nursing Supervisor | Identified as nursing supervisor on date of resident elopement. |
| Corporate Nurse (CN) #1 | Corporate Nurse | Interviewed regarding elopement drills and policies. |
| Director of Maintenance (DOM) | Interviewed regarding door checks and wander guard system. | |
| Service Manager (SM) | Interviewed regarding wander guard system functionality. | |
| Laundry Worker (LW) #1 | Laundry Worker | Mentioned in relation to resident found outside and wander guard alarm. |
| Nurse Aide (NA) #4 | Nurse Aide | Mentioned in relation to door alarm observations. |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Mentioned in relation to checking wander guard bracelet. |
| Nurse Aide (NA) #5 | Nurse Aide | Mentioned in relation to hearing door alarm. |
| Registered Nurse (RN) #2 | Nurse Supervisor | Mentioned in relation to resident found outside and wander guard testing. |
| Nurse Aide (NA) #6 | Nurse Aide | Mentioned in relation to resident outside on patio. |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Mentioned in relation to resident window incident and nursing report. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 19, 2019
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on July 19, 2019 and August 12, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to violations of Connecticut General Statutes and/or Regulations of Connecticut State Agencies.
Complaint Details
Complaint #25892 was the basis for the investigation.
Findings
The facility was found noncompliant with regulations related to respiratory assessments and medication administration for residents reviewed. Specific deficiencies included failure to conduct respiratory assessments when residents showed changes in condition and failure to document medication administration as ordered by physicians.
Deficiencies (2)
Failure to conduct respiratory assessments when residents showed a change in condition and failure to ensure residents were assessed by a Registered Nurse when condition changed.
Failure to document on the Medication Administration Record that an antibiotic medication was administered in accordance with the physician's order and that the medication had not been omitted.
Report Facts
Dates of visits: July 19, 2019 and August 12, 2019
Plan of correction submission deadline: August 31, 2019
Resident sample size: 6
Medication administration days: 7
Audit frequency: Weekly audits of residents with respiratory infections and medication administration records
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter regarding the investigation and plan of correction |
| Cory Cheyne | Administrator | Facility administrator addressed in the letter |
| Director of Nursing (DON) | Interviewed regarding expectations for respiratory assessments and medication documentation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 9, 2019
Visit Reason
Unannounced visits were made to Apple Rehab Rocky Hill on May 9, 10, and 20, 2019 by the Department of Public Health for the purpose of conducting an investigation of noncompliance with Connecticut General Statutes and/or Regulations.
Findings
The facility was found to have violations related to failure to establish a protocol for follow-up on culture reports and communication with consulting physicians regarding antibiotic therapy for a sampled resident. The findings detailed issues with documentation, monitoring, and communication concerning antibiotic treatment and infection control.
Deficiencies (1)
Failure to establish a protocol to ensure follow-up of culture reports and communication with consulting physician regarding antibiotic effectiveness for Resident #1.
Report Facts
Inspection visit dates: 3
Plan of correction submission deadline: 13
Antibiotic treatment durations: 7
Antibiotic treatment durations: 14
Dates of clinical notes and orders: 2018
Plan of correction effective date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter regarding the plan of correction |
| James Thompson | Administrator | Named as the facility administrator in the report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 120
Deficiencies: 9
Date: Dec 18, 2018
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint numbers related to alleged violations of Connecticut State Agencies regulations at Apple Rehab of Rocky Hill.
Complaint Details
The visit was complaint-related involving multiple complaint numbers including 24302, 24443, 24148, 23835, 23725, 23353, 23028, and 22726. The complaints were substantiated with findings of noncompliance in multiple areas.
Findings
The investigation identified multiple violations including failure to follow advance directives, inadequate investigation of injury allegations, failure to notify the Long-Term Care Ombudsman of hospital transfers, inaccurate coding of PASRR, failure to conduct neurological assessments after falls, failure to protect residents from injury, failure to administer vaccines properly, and failure to ensure residents wore identification bracelets.
Deficiencies (9)
Failure to follow advance directives and failure to involve resident in care decisions.
Failure to conduct comprehensive investigation of injury of unknown origin.
Failure to notify Office of the State Long-Term Care Ombudsman of resident hospital transfer.
Failure to ensure PASRR was accurately coded and documented.
Failure to conduct neurological assessments after falls and to protect residents from injury.
Failure to administer pneumococcal vaccines and maintain accurate vaccination records.
Failure to ensure residents wore identification bracelets and to monitor refusal.
Failure to ensure proper dental care and timely dental services.
Failure to maintain safe water temperatures and protect residents from injury related to hot water.
Report Facts
Complaint numbers: 8
Resident counts: 8
Dates of onsite inspections: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Thompson | Administrator | Personnel contacted during the inspection and named in the report. |
| Uly Mueller | Report Submitter | Submitted the inspection report dated 12/19/18. |
| Norma Schuberth | Supervising Nurse Consultant | Signed the important notice letter related to the inspection. |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Dec 18, 2018
Visit Reason
The document is a Plan of Correction (POC) submitted in response to violations identified during an unannounced visit and survey conducted by the Department of Public Health at Apple Rehab of Rocky Hill, concluding on December 18, 2018.
Findings
The report details multiple violations related to resident care, documentation, notification procedures, medication administration, infection control, and staff education. The facility submitted corrective actions including staff re-education, audits, policy reviews, and monitoring to achieve substantial compliance.
Deficiencies (10)
Failure to involve Resident #3 in advance directive discussions and follow directives.
Failure to conduct a comprehensive investigation to rule out mistreatment for Resident #34.
Failure to notify the Office of the State Long-Term Care Ombudsman of Resident #38's hospitalization.
Failure to ensure accurate coding of PASRR for Resident #10.
Failure to conduct neurological assessments and ensure protective clothing for residents with falls or behavioral symptoms.
Failure to protect Resident #55's lower extremities from repeated injury and failure to maintain safe water temperatures.
Failure to administer dietary supplements and ensure re-weighting per physician orders for Residents #21 and #62.
Failure to ensure Resident #59 was seen by dental services timely and according to facility policy.
Failure to obtain and administer complete and accurate pneumococcal vaccination history and consent for multiple residents.
Failure to ensure residents wore identification bracelets and maintain accurate photographs.
Report Facts
Date of Compliance: Jan 29, 2019
Date of Compliance: Jan 16, 2019
Resident Age: 86
Resident Age: 77
Resident Age: 75
Resident Weight: 159.7
Resident Weight: 150.6
Laceration Size: 4
Bruise Size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Thompson | Administrator | Signed the Plan of Correction letter |
| Norma Schuberth | Supervising Nurse Consultant | Recipient of the Plan of Correction letter |
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