Generations at Applewood

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to assess and document resident vital signs for a resident experiencing a change in condition and failed to ensure a resident received timely emergency treatment for one resident reviewed on the sample list of 33. These failures resulted in R7's delay in transferring to a higher level of care to receive emergency care after R7's change in condition. B. Based on observation, interview and record review, the facility failed to implement skin prevention interventions and failed to identify skin integrity impairments for two residents reviewed for skin integrity. These failures affect two residents (R32, R89) reviewed for skin integrity on the sample list of 33. C. [...]

Inspectors wroteBased upon observations, interviews, and record review the facility failed to implement preventive interventions to maintain skin integrity, failed to ensure that the LALM (Low Air Loss Mattress) as on the correct settings while in use, failed to ensure that multiple linen layers were not beneath the resident while on a LALM, failed to timely identify skin integrity impairments, failed to follow physician orders, and/or failed to document/administer prescribed treatments for 10 of 33 residents (R8, R11, R12, R47, R52, R55, R90, R100, R118, R121, R123) in the sample reviewed for pressure ulcers. These failures resulted in R118 developing a (facility acquired) infected (stage 4) sacral wound on or about 5/5/26 which required hospitalization, antibiotic medication, and surgical debridement.

Inspectors wroteBased on interview and record review, the facility failed to notify R2's attending physician of a scheduled extensive dental extraction procedure. The facility also failed to communicate with the cardiologist and/or attending physician of R2's use of multiple blood thinning medications and request orders related to these medications in relation to R2's scheduled extensive dental extraction procedure. These failures affect one resident (R2) of three residents reviewed for quality of care. These failures caused R2 to experience uncontrolled hemorrhaging from R2's gums/oral cavity after having extensive extraction of ten teeth. R2 required emergent transfer to the local hospital. R2 was admitted from the emergency room to the hospital with a diagnosis of Oral Hemorrhage requiring transfusion of multiple blood products.

Inspectors wroteBased on interview and record review, the facility failed to notify family and the attending physician of a dental appointment with procedure scheduled outside of the facility. These failures affects one resident (R2) of three residents reviewed for family and physician notification for changes.

Inspectors wroteBased on interview and record review the facility failed to follow their fall policy by failing to implement effective fall interventions, failed to thoroughly investigate each fall to determine root cause analysis, failed to conduct fall risk assessments after two falls and failed to conduct neurological checks for one resident (R3) out of three reviewed for falls. These failures resulted in R3 sustaining four unwitnessed falls and being diagnosed with a right femur fracture.

Inspectors wroteBased on interview and record review, the facility failed to follow their pain policy and provide effective pain management for one resident experiencing severe right knee pain after a fourth unwitnessed fall. These failures affect one of three residents (R3) reviewed for pain management. These failures resulted in the resident experiencing severe pain, revoking hospice services and being transferred to the hospital with a diagnosis of right femur fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its abuse prevention policy by neglecting to provide the necessary personal care and assistance with ADLs (activities of daily living) to meet the residents needs. This failure affected all 30 residents residing on one nursing unit.

Inspectors wroteBased on interview and record review the facility failed to follow its ADL ( Activities of Daily Living) policy and provide incontinence care and turning/repositioning for four residents ( R1, R10, R12, and R13) who are totally dependent on two staff for all ADL care, with the potential to affect all 30 residents residing on one nursing unit.

Inspectors wroteBased on interview and record review, the facility failed to follow its fall prevention and management policy and review and revise one resident's care plan after each fall. The facility also failed to implement effective interventions to eliminate or reduce resident's fall risk. This failure affects one resident (R3) out of three reviewed for falls in a sample of 36.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to follow its call light policy and ensure the call light cord was within reach for 4 residents (R3, R5, R6, and R7) out of 4 residents reviewed for call light accessibility in a sample of 7.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to identify, evaluate and eliminate hazards, and provide adequate supervision to prevent an avoidable accident in accordance with current professional standards of practice for one residents (R4) out of three residents reviewed for avoidable falls in a sample of 7.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to maintain its call light system in good working condition for one resident (R3) out of four residents reviewed for working call lights in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to prevent facility acquired pressure ulcer injury to residents at risk for pressure ulcers. The facility also failed to initiate wound treatment for facility acquired pressure ulcer. These failures affect two residents (R2, R5) of three residents reviewed for pressure ulcer/skin alteration. These failures resulted in R2 developing a facility acquired pressure ulcer injury and R5 developing three facility acquired pressure ulcer injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was properly secured while being transported using the facility's private transport vehicle. This failure affects one of three residents (R3) reviewed for falls. R3 fell forward inside the facility's private trasnport vehicle and sustained a right intertrochanteric femur fracture requiring surgical repair of Intramedullary nailing of the right proximal femur.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy and notify the State Survey Agency within the required two-hour timeframe of allegations of abuse and injury of unknown origin for six residents (R1, R2, R3, R4, R5, and R9) out of seven residents reviewed for abuse in a sample of 10.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plans for four residents (R1, R2, R3, and R4) identified as at risk for abuse out of four residents reviewed for abuse in a sample of 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify causes of resident weight loss; failed to identify that a resident had AIDS (acquired immunodeficiency syndrome); failed to monitor R3's HIV diagnosis according to professional standards; failed to develop a plan of care to address known weight loss and refusals of care; failed to notify providers of abnormal lab results; failed to notify providers of severe weight loss; failed to follow physician orders for lab work; failed to notify the provider/implement dietician recommendations timely. These failures affect 1 resident (R3) reviewed for quality of care. These failures caused harm to R3 as evidenced by a 5.5% weight loss in 6 days, an 8.2% weight loss within a month and a 16% weight loss within 3 months.

Inspectors wroteBased on interview, observation and record review, the facility failed to develop and implement pressure ulcer prevention intervenctions for three of 12 residents (R49, R24, R120) reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving psychotropic medications have a gradual dose reduction attempt or documented clinical contraindication for not attempting. This failure affects one resident (R77) of three reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a plan of care for one resident who was diagnosed with urinary retention requiring a urinary catheter. This failure affects one of two residents (R118) reviewed for urinary catheter care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care for a resident. This failure affects one of three residents (R90) reviewed for incontinence care. Findings Include: R90 had the diagnosis of Obesity, hemiplegia and hemiparesis following cerebral infraction affecting the left non- dominant side. Brief interview for mental status dated 2/26/25 documents R90's cognition as intact. Minimal data set section GG dated 5/7/25 documents: dependent with toileting. Section HH (Bowel and Bladder) urinary continence-always incontinent. On 5/7/25 at 1:41pm, R90 was observed with the call light on. R90 who was assessed to be alert to person, place and time, said she was wet. R90 said, the last time she was provide incontinence care was at 4:00am. R90 said, V6, Certified Nursing Assistant (CNA) informed her she wound provide care after lunch. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent one dependent resident (R30) from developing a large stool ball. This failure affects one of one residents (R30) reviewed for quality of nursing care. This failure resulted in R30 being hospitilized with a diagnosis of fecal impaction.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for providing urinary catheter care every shift for residents with indwelling catheters. The facility also failed to obtain and document a diagnosis in the physician's orders for an indwelling catheter. These failures affect two of two residents (R80, R118) reviewed for suprapubic and indwelling urinary catheters.

Inspectors wroteBased on interview and record review, this facility failed to provide services to assist residents with scheduling outside physician appointments and arranging transportation to and from appointments. This failure affects one resident (R84) out of three residents reviewed for follow-up appointments after a hospital emergency visit for a fractured left femur.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician prescribed diet order for double portions of meat at lunch for one of three residents (R126) reviewed for therapeutic diet. Findings Include: R126's physician order sheet dated 4/7/25 documents: Regular texture thin, for diet. Give double meat with lunch. R126's diet card documents: double meat with lunch. On 5/6/25 at 12:27PM, R126 was observed eating lunch with one piece of meat on his tray. On 5/6/25 at 1:57PM, R126 said, who was assessed to be alert and oriented to person, place and time said, he had one piece of meat for lunch. On 5/8/25 at 3:00PM, V17 (dietary manager) said, R126 was served beef fritters on 5/6/25. Double portion for meat would be two piece of meat on the tray. Therapeutic diets are orders that need to be followed. Facility lunch menu documents: [...]

Inspectors wroteBased on interview and record review, this facility failed to provide skilled therapy services to one resident (R84) who sustained a left femur fracture after a fall at the facility, while being transferred from bed to chair. This affected one of three residents R84 reviewed for skilled therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and change a central venous catheter dressing for one resident within at least 5-7 days. This affects one of eight residents R49 reviewed for infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to implement pressure sore prevention interventions, including the use of a low air loss mattress, and failed to perform dressing changes to the sacral wound and conduct daily skin assessments as ordered. The facility failed to document when and under what condition the sacral wound was initially identified. This failure affects one of the three residents (R3) reviewed for wound care and prevention interventions.

Inspectors wroteBased on interview and record review the facility failed to follow their control substance policy and ensure the medication hydrocodone 5-325 milligrams are documented and accounted for, for two of two residents (R4 and R5) reviewed for controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to safely position a resident in the bed while providing incontinence care and prevent a resident from rolling out of the bed onto the floor. This affected one of three residents (R6) reviewed for safety during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to prevent development of a pressure ulcer; failed to promote wound healing and prevent infection for a dependent resident who was assessed as being at risk for pressure ulcer; and failed to perform weekly skin assessments as ordered. These failures applied to one (R1) of three residents reviewed for pressure ulcers and resulted in R1 developing a stage 4 facility acquired pressure ulcer to her sacrum, which required hospitalization for treatment of infection and surgical wound debridement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff use proper personal protective equipment (PPE) when caring for residents on enhanced barrier precaution, failed to ensure that respiratory equipment mask was properly contained, and failed to ensure that staff follow proper hand hygiene practices during wound care for a resident. These failures affected two (R1, R2) of two residents reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident received hygiene care to keep nails clean and short for 1 of 3 residents (R2) reviewed for activities of daily living in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the failed to ensure a resident received an oral medication and topical creams as prescribed for 2 of 3 residents (R1, R2) reviewed for medications in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided in a manner to prevent cross contamination for 1 of 3 residents (R2) reviewed for incontinence care in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to perform a safe transfer by not using the mechanical lift for 1 resident (R2) dependent on staff for transfers. This failure affected one of three residents reviewed for injury. This failure resulted in R2 sustaining an acute mildly displaced fracture of the distal femoral diaphysis on the left leg. This past non-compliance occurred from 11/7/24 to 12/4/24.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received admissions paperwork including notice of rights, rules, and responsibilities during their stay, prior to, or upon admission. This failure applied to three of four residents (R3, R4, and R5) reviewed for residents rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and ensure effective interventions were in place to reduce the risk of falls/falls with injury for three of three residents (R58, R69 and R80) in the sample of 22 reviewed for fall prevention program. This failure resulted in R80 being sent to the local hospital sustaining a left femoral fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply anti-embolism (TED) elastic stockings to prevent swelling of bilateral lower extremities as ordered by physician. This deficiency affects one (R73) of three residents in the sample of 22 reviewed for providing treatment as ordered by physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders and implement care plan interventions to apply splint to prevent contracture to resident who has limited range of motion. This deficiency affects one (R86) of three residents in the sample of 22 reviewed for Restorative Nursing Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit (F), failed to ensure a resident was positioned safely while providing direct resident care, and failed to develop fall prevention interventions to include monitoring for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. This failure affected 3 of 3 residents (R1, R3, R2) and resulted in R1 spilling coffee sustaining full thickness burns to the right posterior thigh measuring 13.9x6.3x0.1cm (centimeters) and to the left thigh measuring 4.8x18.5x0.1cm. This failure also resulted in R3 rolling out of the bed sustaining a laceration to left eyebrow, subarachnoid hemorrhage, and a nondisplaced patella (knee) fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide feeding assistance for residents with visual deficits that were identified as needing assistance which resulted in an unplanned serve weight loss. This affected two of three residents (R8, R9) reviewed for unplanned weight loss. This failure resulted in R8 having a weight loss of 8.99% in one month and R9 having a weight loss of 10.6% in four months. Findings Include: 1) R8 has a diagnosis with Dementia. On 05/24/24 at 12:21PM and 12:33PM, R8 was observed with her head tilted to the ceiling with a non-focusing blank stare while eating in the dining room with no feeding assistance. R8 was observed scooping pureed food off her plate onto the tray, putting the spoon in her mouth with no food on it. R8 dropped the spoon on the tray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their hot beverage policy by not ensuring coffee was below 140 degrees Fahrenheit and not logging coffee temperatures prior to each service. This affected one of three residents (R1) reviewed for temperature of coffee served to residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their change in condition policy by not notifying the family (responsible party) and hospice in a timely manner of a fall incident. This affected one of three residents (R2) reviewed for notification of a change. Findings Include: R2 was diagnosed with Dementia with behavior disturbance, general anxiety disorder, restlessness and agitation. Hospice referral paperwork dated 2/19/24 documents: notify hospice of falls or injuries. Nursing note dated 2/29/24 document: Received detailed report from hospice, resident (R2) is alert to self only. At home resident is never left alone because she has a tendency to attempt to walk unassisted or sit on the floor. On 05/22/24 at 12:34pm, V3 (Assistant Director of Nurses/ADON) said, if R2's family was notified it would be documented. [...]

Inspectors wroteBased on interviews and observations the facility failed to supervise an impulsive, confused resident, with unsteady gait from getting into bed with another resident. This affected two of three (R1, R2) residents reviewed for supervison/monitoring. This failure resulted in R1 screaming, crying, and feeling nervous after R2 climbed into her bed. A reasonable person would have been scared and terrified.

Inspectors wroteBased on interview and record review, the facility failed to follow their change in condition policy, and to provide emergency life sustaining measures for one (R8) of five residents reviewed for change in condition and emergency life sustaining measures in a sample of 17. This failure resulted in an Immediate Jeopardy when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. The Immediate Jeopardy began on [DATE] when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. V1 (Administrator) was notified on [DATE] at 11:46 am. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that oxygen was administered to a resident with labored breathing and failed to notify the physician of the change in condition for one of five residents (R8) reviewed for accommodation of needs in a total sample of 17. This failure resulted in R8 becoming unresponsive and apneic with a faint carotid pulse and expiring in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 1 of 3 residents (R13) reviewed for safety, this deficiency resulted in R13 falling out of bed on 11/26/2023 and being sent to the local emergency hospital, sustaining an acute intraparenchymal hemorrhage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had their own clean clothes to wear and failed to ensure that laundry was replaced after being lost or damaged for 4 of 8 residents (R6, R7, R15, R16) that were reviewed for laundry in a sample of 16.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call lights were within reach and easily accessible for 4 of 7 residents (R3, R4, R5, R6) reviewed for accommodation of needs in a sample of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all resident rooms were adequately cleaned and free of clutter for 4 of 7 residents (R2, R3, R4, R5) reviewed for cleanliness and home-like environment in a sample of 12.

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy in notifying a physician of a change in condition for one (R8) of five residents reviewed for change in condition notification in a sample of 17. This failure resulted in R8 being unresponsive, apneic with a faint pulse and expiring. Findings Include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) care to 2 of 7 dependent residents (R2, R6) reviewed for grooming in a sample of 12. Findings Include: On 11/28/2023 at 3:08pm R2 was observed in bed unshaved and nails long. R2 shook his head yes to wanting a shave and nails trimmed. On 11/28/2023 at 3:10pm V4 (Nurse) observed with the writer R2 nails. On 11/28/2023 at 3:11pm V4 said the morning certified nursing assistants -CNA should have shaved and trimmed R2's nails, I'll get him some assistance. On 11/28/2023 at 3:15pm V2 (Director of Nursing-DON) said I expect all morning care to be given daily, this is not okay. R2's resident face sheet indicates that R2 has a diagnosis of hemiplegia and hemiparesis. A care plan dated 10/24/2023, has an approach to provide assistance with ADL'S as needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep call lights within reach for four (R9, R43, R85, and R251) out of 12 residents reviewed for call lights in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene after contact with feces and urine and placed the soiled linens on the floor during incontinence care. The facility also failed to store the nebulizer unit in a clean plastic bag. This affects four residents (R41, R43, R68 and R61) in the sample of 25 reviewed for infection control protocol.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the advance directive for one of six residents (R76) reviewed for advance directive in a sample of 25 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered plan of care for a resident who receives oxygen. This deficiency affects one (R151) of three residents in the sample of 25 reviewed for Comprehensive care plan.

Inspectors wroteBased on observation, interview and record review, the facility failed to carry out a physician order for fluid restriction by failure to monitor and record fluid intake of resident on strict fluid restriction due to Congestive heart failure. This deficiency affects one (R83) of three residents in the sample of 25 reviewed for Professional Standard of Care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oral hygiene to a totally dependent resident. This deficiency affects one (R48) of three residents reviewed for providing Activity of Daily Livings (ADLs).

Inspectors wroteBased on observation interview and record review, the facility failed to prevent and identify skin breakdown and provide appropriate treatment in a timely manner. This deficiency affects one (R83) of three residents reviewed for Skin Assessment/Skin Management Protocol.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a hand split on one resident (R67) out of 12 residents observed for hand splints in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen as ordered by the physician for one of four residents (R78) observed for oxygen therapy in a sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing assessment and oversight of the residents after dialysis treatment. This deficiency affects two (R7 and R14) of four residents in the sample of 25 residents reviewed for Dialysis Management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Residents are free of any medication errors of 5% or greater for two residents R12 and R77 of twenty-five opportunities observed for medication administration in a sample of 25 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Residents are free of medication errors of 5% or greater for two residents R12 and R77 of twenty-five opportunities observed for medication administration in a sample of 25 residents.