Quality Life Services - Apollo

Inspectors wroteBased on review of facility policy, resident observations, resident and staff interviews, Resident Council Minutes, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four of eleven residents (Resident R1, R2, R3, and R4), and for two of three Resident Council monthly meetings (May 2026, and June 2026).

Inspectors wroteBased on review of facility policy, clinical records, incident reports, hospital records, facility provided documents, resident interview, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer in the facilities vehicle van, which resulted in actual physical harm (an abrasion to crown of head, abrasion to right knee, abrasion to left ankle, and three acute cervical (neck) fractures of C3, C4, and C5) for one of two residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers (Resident R1).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide nephrostomy (nephrostomy tube is a thin catheter that drains urine from your kidney into a bag) care and services consistent with physician orders for one of two residents reviewed (Residents R1).

Inspectors wroteBased on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three resident reviewed (Resident R1), which resulted in actual harm of a resident, resulting in a head laceration requiring transfer to the hospital.

Inspectors wroteBased on review of facility policy, clinical and facility record review, facility provided documents, and staff interviews, it was determined the facility failed to provide adequate supervision for two residents resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for two of 33 residents (Residents R1 and R2) identified as having a high risk for wandering.

Inspectors wroteBased on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of two resident (Residents R1 and R2), which created an immediate jeopardy situation for two of 33 residents.

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Closed Resident Record CR1). A review of the clinical record indicated that Closed Resident Record CR1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of kidney, major depressive disorder and hypertension (pressure in your blood vessels are too high). A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 7/30/25, indicated the diagnoses remained current. A review of Closed Resident Record CR1 nurse progress notes 9/30/25 indicating resident ceased to breath (CTB) on 9/26/25 at 1915. A review of Closed Resident Record CR1 nurse progress notes did not include documentation on 9/26/25. [...]

Inspectors wroteBased on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician for two of two residents (Resident R19 and R182), resulting in significant medication errors due to receiving another resident's medications for one of five residents reviewed (Resident R182). This created actual harm which required a transfer to the emergency department and admission to a telemetry unit (a unit of a hospital where patients receive continuous heart monitoring) for Resident R182.

Inspectors wroteBased on a review of facility policy, observation and staff interview, it was determined that the facility failed to monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly and failed to properly maintain cleanliness and sanitation of the Kitchen areas (Main Kitchen).

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to make certain that equipment was in safe operating condition for three of three crash carts (GRU, Angel Wing, and Buttercup) and one of one AEDs (Automatic External Defibrillators).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R35 and R182), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Residents R25, R35, and R182).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for five of six residents (Residents R11, R22, R28, R73, and R100).

Inspectors wroteBased on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for three of six residents (Residents R22, R38, and R79).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for three of nine residents (Residents R25, R105, and R186).

Inspectors wroteBased on review of facility document, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for four of four residents (Resident R12, R57, R58, and R116).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two of two medications rooms (Angel Wing Medication Room and GRU Medication Room), and two of three medication carts (Angel Wing Back Medication Cart and GRU Back Hall Medication Cart).

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of four residents (Resident R25).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R35 and R79).

Inspectors wroteBased on review of facility policy, observation, clinical record review and staff interview it was determined that the facility failed to obtain a physician order, develop a resident centered care plan, and determine resident safety for the placement of a bed against the wall for two of two residents (Resident R103, and R106).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set assessments were completed within the required time frame for one of six residents (Resident R73).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for two of three residents (Residents R12 and R22).

Inspectors wroteBased on clinical records and staff interview, it was determined that the facility failed to revise a care plan to accurately reflect the current status for one of six residents (Resident R65).

Inspectors wroteBased on review of facility policy, job descriptions, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice by failing to administer medications to the correct resident for one of five residents (Resident R182).

Inspectors wroteBased on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide supervision with meals as ordered for one of three residents (Resident R23).

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents (Residents R116).

Inspectors wroteBased on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (R79).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of four residents (Resident R25).

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility failed to ensure the physician reviewed the resident's total program of care for one of five residents (Resident R105).

Inspectors wroteBased on review of personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for three out of five nurse aides (NA Employee E13, E14 and E15).

Inspectors wroteBased on a review of four-week cycle menu, and staff interviews, it was determined that the facility failed to have a registered dietitian review and approve the menu and nutritional substitutes prior to implementation for one out three meals served on 4/25/25 (lunch).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of three residents (Resident R38).

Inspectors wroteBased on review of facility policy, resident clinical records, facility documents, and staff interviews, it was determined that the facility failed to timely enter an order for isolation for one of nine residents (Resident R68) and have a surveillance plan for tracking, and monitoring residents who tested negative for Influenza during an outbreak for two of ten months (February 2025 to March 2025).

Inspectors wroteBased on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (leaving an area without permission) for one of 16 residents (Resident R1), and failed to make certain each resident received adequate monitoring of an elopement prevention device for one of 16 residents (Resident R2).

Inspectors wroteBased on observations, resident interview, and staff interview it was determined that the facility failed to have complete contact information for State Long-Term Care Ombudsman program posted at the facility.

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four units (Geriatric Rehabilitation Unit Back Medication Cart).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to obtain an order for a resident with a tracheostomy (a procedure to help air and oxygen each the lungs by creating an opening into the windpipe from outside the neck), to ensure proper tracheostomy care for one of three residents (Resident R1).

Inspectors wroteBased on clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of six residents (Resident R1, R2) to accurately reflect the current status of the resident.

Inspectors wroteBased on facility policy review, clinical and facility record review, facility provided documents and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exited to an unsupervised and unauthorized location without staff's knowledge) for one of six resident (Resident R1).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of seven residents sampled with facility-initiated transfers (Residents R41, R49, R68, R116, and Closed Resident Record CR134).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of seven residents (Residents R41, R49, R68, R116, and Closed Resident Record CR134).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for four of four residents (Residents R23, R38, R78, and R337).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to monitor resident wounds and complete weekly skin assessments for four of four residents (Residents R52, R66, R88, and R96), failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order for one of two residents (Resident R49), and failed to follow physician orders to monitor daily weights for one of three residents (Resident R116).

Inspectors wroteBased on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for four of four residents (Resident R50, R67, R68, and R128).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two out of three medication carts (Pleasant Valley Back Medication Cart and Buttercup Back Hallway Medication Cart) and one of three medication rooms (Angel Wing Medication Room).

Inspectors wroteBased on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Closed Record (CR) Resident R1).

Inspectors wroteBased on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of four three units (Pleasant Valley Back Medication Cart).

Inspectors wroteBased on review of facility policies and clinical records, and staff interviews it was determined that the facility failed to assess the functional status of one of two resident (Resident R99) to determine if the use of a seatbelt is a restraint, and failed to develop a care plan for a seatbelt for one of two residents (Resident R2)

Inspectors wroteBased on a review of the clinical record and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one of six residents (Resident R90).

Inspectors wroteBased on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to provide colostomy (a surgical process that diverts bowel through an artificial opening in the abdomen wall) care and services consistent with professional standards of practice for one of two residents reviewed (Resident R76).

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for one of four residents reviewed (Resident R81).

Inspectors wroteBased on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of six residents (Resident R84).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to ensure a resident with dementia receives the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for one of four residents reviewed (Resident R7).

Inspectors wroteBased on review of facility policy, Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of one of three quarters (January 2024 through March 2024).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for three out of three residents (R22, R76, and R110).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to one of five residents (Resident R25).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to notify a physician of abnormal vital signs for one of four residents (Resident R1).

Inspectors wroteBased on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for one of four residents (Resident R1).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for a foley catheter and ostomy as required for one of five residents (Resident R1).

Inspectors wroteBased on facility documents, clinical record review and staff interview, it was determined that the facility failed to make certain that a resident with limited bed mobility received services to maintain safety and maintain or improve bed mobility for one of three residents (Resident R1).

Inspectors wroteBased on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to provide adequate supervision for bed mobility for one of three residents, that resulted in a resident falling out of bed (Resident 1).

Inspectors wroteBased on review of clinical records and staff interviews it was determined that the facility failed to identify a case of Legionella, evaluate and analyze hazards and risks, and implement interventions to reduce hazards and risks in a timely manner for one of three residents reviewed (Resident R1).

Inspectors wroteBased on facility policy, observation, and staff interview, it was determine the facility failed to provide privacy and confidentiality of resident healthcare information on three of three residents (Resident R7, R57, R70, and R118).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement comprehensive care plans to meet care needs for five of twenty-nine residents (Residents R31, R49, R63, R91, and R100).

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for three of twenty-nine residents (Residents R21, R108, and R54).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete annual performance evaluations for four out of five personnel records (Nurse Aide (NA) Employee E15, Nurse Aide (NA) Employee E16, Nurse Aide (NA) Employee E17, and Nurse Aide (NA) Employee E18).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to develop and implement infection prevention and control policies for COVID-19 that were current and based on national standards and complete COVID-19 testing as recommended by national standards for two of two residents (Residents R72 and Resident R113).

Inspectors wroteBased on review of facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for one out of three sampled residents (Resident R144).

Inspectors wroteBased on review of facility policy, resident clinical record, investigation documentations, family interview and staff interviews, it was determined that the facility failed to conduct a thorough investigation involving an allegation of neglect for two out of three sampled residents (Resident R144 and R106).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that resident assessments were accurate for two of five residents (Residents R63 and R91).

Inspectors wroteBased on staff interview, record review, and state scope of practice, it was determined that the facility failed to follow professional standards of practice for to one of four residents reviewed (Resident R141).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to administer medications as prescribed by the physician for two of two residents (Resident R48 and R113).

Inspectors wroteBased on review of facility policy and records, and a staff interview, it was determined that the facility failed to provide pressure ulcer treatment consistent with professional standards of practice by ensuring weekly wound assessments and treatment were completed as ordered for two of five residents reviewed (Resident R79 and R141).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to make certain that residents who require dialysis (hemodialysis-treatment to filter wastes and water from the blood) receive services, consistent with professional standards of practice for two of three residents (Resident R48 and R18).