Apex Secure Care Brownfield

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective Infection Control Program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 2 of 11 residents (Resident #32 and Resident #36) reviewed for infection control. LVN A provided wound care to Resident #32 with contaminated supplies: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 3 of 24 resident rooms (E2, E9, and F3) and 1 of 1 areas for visitation reviewed for environment. 1. The facility failed to ensure residents that used common areas and rooms were clean, safe, and did not need repair. 2. The facility failed to have a designated visitation area with adequate seating for visitors and residents. These failures could place residents at risk of living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 6 (10/4/2025, 10/5/2025, 10/11/2025, 10/12/2025, 10/19/2025, and 11/9/2025) of 67 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 6 days. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent cross contamination and the potential for foodborne illness for (64 of 64) residents reviewed for food and nutrition services. 1. The facility failed to ensure opened food items open in the refrigerator and dry storage areas were labeled with the open or use by date.2. Food transportation carts were dirty.3. Clean plates, serving utensils, and pans were stored facing upwards stored on a table.4. The facility failed to ensure staff followed hygienic practices for proper hand hygiene and use of hair restraints.5. The facility failed to ensure [NAME] D used gloved hands instead of utensils to handle prepared food, 6. Bleach, lime scale, and soak tank concentrate were stored on the floor in the food prep area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 1 of 1 dining rooms, 1 of 2 dry pantries (Dry Pantry A), around 1 of 1 nursing stations and 1 of 7 Hallways (Hall C), in that: The facility failed to ensure the dining room floors were in good condition. The facility failed to ensure the dining room ceiling was in good condition and not leaking. The facility failed to ensure Dry Pantry A's ceiling was in good condition and not leaking. The facility failed to ensure the floors around the nursing station were in good condition. The facility failed to ensure Hall C did not have water damage on the ceiling tiles outside Room C9. These failures could lead to resident injuries, falls, spread of infections and cause the facility to have an unsightly appearance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 21 residents (Resident #32) reviewed for respect and dignity. LVN A failed to provide privacy for Resident #32 when LVN A failed to close the window blinds, the door, or the privacy curtain during wound care. This failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 (Dinner) meal reviewed for food and nutrition services. The facility failed to provide food that was palatable for the dinner meal on 04/13/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to maintain sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 (LVN C) nursing staff reviewed in that: The facility failed to ensure LVN C maintained an active nursing license while working as a nurse. The failure could place residents at risk of receiving care from an unlicensed professional.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen oven door remained closed and secure. This failure could place residents at risk for receiving unevenly cooked meals and at risk for fire emergencies.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the hallways were equipped with firmly secured handrails on each side for 1 of 6 (Hall C) hallways reviewed in that: The facility failed to ensure the handrail in Hall C between Rooms C3 and C4 was firmly attached to the wall. This failure could lead to resident injuries or falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 8 of 16 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8) reviewed for clinical records. The facility failed to ensure evening medications refused by Residents #1, #2, #3, #4, #5, #6, #7 and #8 were accurately documented in the Medication Administration Record by CMA A, on 09/21/25. This failure could place residents at risk of not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (treatment cart for Hall A, B and C) reviewed for proper medication storage. LVN C failed to ensure the treatment cart, which contained medications, was not left unlocked and unsupervised in the hallway near the nurse's station. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions. During an observation on 10/02/25 at 1:59 PM, the treatment cart for Hall A, B and C was observed sitting outside the nurse's station and was unlocked and unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 of 20 residents (Resident #27, #51, #328, and Resident #16) reviewed for infection control. 1. CNA A failed to utilize hand hygiene when assisting Residents #27, #51, and #328 with their meals on 2/09/2025. 2. LVN B failed to utilize hand hygiene between glove changes when providing wound care to Resident #16 on 2/10/2025. These failures could place residents at risk for infection, and cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. The residents' hand sink in room D5 was not operational for 2 of 3 days. 2. The hand sink in the women's restroom was not operational for 2 of 3 days. 3. The hand sink and toilet in room A8 was not operational for 1 of 3 days. 4. The hand sink and toilet in room A6 was not operational for 1 of 3 days. These failures could place residents and the public at risk of a diminished quality of life due to exposure to an environment that is nonfunctional, uncomfortable, unsanitary, and unsafe.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 (Resident #2) of 21 residents. The facility failed to ensure Resident #2 was treated with respect, dignity, and care when they failed to ensure Resident #2's room was cleaned daily, furnished with a covering on her bedroom window, and a furnished with a privacy curtain. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included: [...]

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure each resident had a right to reside and recieve services in the facility with reasonable accomodation of the resident's needs and preferences for 1 (Resident #2) of 21 residents reviewed for accomodation of needs. The facility failed to provide a working communication system, that was easily at reach at the bedside, that would allow Resident #2 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.

Inspectors wroteBased on observation, interviewn and record review, the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 (Resident #2) of 21 resident's rooms and restrooms reviewed for environment. The facility failed to ensure Resident #2's room was cleaned daily, homelike, clean, safe, and did not need repairs. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 6 residents (Resident #16) reviewed for PASRR screening, in that: Resident #16 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, facility-sponsored group, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 3 of 21 residents reviewed for activities. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure menus were followed for all residents for 2 of 3 (02/10/25 noon meal and 02/11/25 noon meal) meals observed. The facility failed to follow the week 4 menu for two lunch services served at the facility on Monday 02/10/25 and Tuesday 02/11/25. These failures could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 3 of 3 refrigerators reviewed for food safety (Room D6, D8, and E9) in that: The refrigerator located in Room D6 did not have a temperature log present for the refrigerator. The refrigerator located in Room D8 did not have a temperature log present for the refrigerator. The refrigerator located in Room E9 did not have a temperature log present for the refrigerator. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 received direct supervision from staff on while smoking when Monitor Tech A was observed on a cell phone while assigned to monitor residents in the smoking area on 11/22/2024. 2. Monitor Tech A failed to follow protective measures put in place to use cigarette extenders and smoking aprons for residents' safety while residents were outside smoking, resulting in a burn to Resident #1 on 11/22/2024. 3. An Immediate Jeopardy situation was determined to have existed on 11/22/24. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1, 2, 3, 4, 5, and 6) of six residents reviewed for abuse. The facility failed to ensure the Abuse and Neglect Policy was implemented by the facility's staff member, when monitoring tech (MT A) abused Resident #1 and M T B, who witnessed this abuse failed to intervene and report it. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to develop and implement a care plan area for physician order for wound treatment of left above the knee amputation (stump). These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that: 1. Resident #1's wounds were left uncovered and exposed on the left side above the knee amputation. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 Residents observed for infection control for practices (Resident #1) in that: 1. Facility staff failed to change Resident #1's humidification bottle of oxygen t. The bottle on the oxygen tank was dated 02/04/2024. Resident #1 was observed actively using her oxygen. 2. CNA A failed to wash hands prior and during incontinent care with Resident #1. CNA A failed to use appropriate PPE during incontinent care for Resident #1 that was on barrier precautions for wounds. 3. LVN failed to wash hands before or during wound care for Resident #1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure food and non-food contact surfaces were clean. 3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. 4) The facility failed to ensure food were accurately dated and labeled. 5) The facility failed to protect foods from potential contamination, and 6) The facility failed to ensure staff used good hygienic practices. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 24 residents (Residents #2, #26) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #2, #26 prior to administering Asenapine Transdermal Patch (an antipsychotic used to treat the symptoms of schizophrenia; a mental illness that causes disturbed or unusual thinking, loss if interest in life, and strong or inappropriate emotions). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 10 of 24 resident rooms (C1, C5, C8, C9, C10, D1, D3, D4, D7 and D8), reviewed for environment, in that: 1)The facility failed to ensure resident use equipment was safe and in good repair (C1, C9, C10, D1, D7 and D8). 2) The facility failed to ensure resident use equipment and areas were maintained in a clean manner (C5, D7 and D8). 3) The facility failed to ensure resident use hot water was maintained at a comfortable temperature which was at core body temperature or above (98.6 degrees F) (C8, D1, D3, D4, D7 and D8). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for 3 of 3 food forms (regular, mechanical soft and puree) for 3 residents (Residents #11, 39 and 48) reviewed during mealtimes. The facility failed to ensure Residents #11, 39 and 48 received their meals according to the menu. This failure could place residents at risk for unwanted weight loss and hunger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen and 1 of 4 corridors (Hall C) in that: 1)Live roaches were observed crawling on the walls and floor in the kitchen and floor of 1 of 4 corridors (Hall C), and 2) The pest control program was further compromised due to the facility having harborage areas that were not repaired (holes in walls and loose wallboard). These failures could place residents at risk for foodborne illness and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 25 residents reviewed (Resident #31) in 1 of 24 resident rooms reviewed: The facility failed to provide a safe environment 1 of 1 resident with a diagnosis of Huntington's disease (Resident #31) related to extension cords on 1/07/24 and 1/08/24. This failure could place residents at risk for injuries from contact with the surrounding environment due to resident involuntary movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 3 of 3 residents (Residents #11, 39 and 48): The facility failed to provide Residents #11, 39 and 48 with their physician ordered therapeutic diets that included pureed, thickened and/or fortified foods for the noon and evening meals on 1/7/24 and the noon meal on 1/8/24. This failure could place residents at risk for hunger, weight loss, aspiration and chemical imbalances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents fed by gastrostomy tube (Resident #31). 1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a manner to prevent complications and prevent staff miscommunication related to Resident #31's care on 1/07/24 and 1/08/24. These failures could result in the spread of resident infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals for 1 of 2 residents (Residents #165) reviewed for dialysis, in that: Resident #165 did not have physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. This failure could affect residents receiving dialysis treatments and place them at risk of not receiving proper medical care related to dialysis services resulting in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 meals (1/7/24 - Lunch, 1/7/24 - Supper and 1/8/24 - Lunch) observed for 2 of 2 residents with orders for puréed diet (Residents #39 and 48). The facility failed to provide food that was in a form to meet resident needs, 3 of 3 meals observed (1/7/24 - Lunch, 1/7/24 - Supper and 1/8/24 - Lunch) for 2 of 2 residents with orders for puréed diets (Residents #39 and 48). This failure could place residents at risk of decreased food intake and choking.