Apple Rehab West Haven

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1's refusal to take the cefuroxime axetil in the nurse's notes reporting she should have. Interview with the APRN on 9/17/25 at 1:28 PM identified she was unaware and had not been notified Resident #1 missed five (5) doses of the cefuroxime axetil due to refusal and going on an LOA, stating had she known, she could have changed the time of the administrations to allow the staff to reapproach Resident #1 at a later time and/or extended the duration of the cefuroxime axetil treatment. The APRN identified t a provider should have been notified for each missed medication dose. Interview with the Director of Nursing (DON)

on 9/17/25 at 2:37 PM identified the provider should have been notified for each missed dose medication and each missed dose was documented to include why the medication was not administered and who was notified following the omission of each medication and any new orders obtained. The DON reported when a resident refuses a medication, nursing should be educating the resident on its importance and then reapproaching the resident if they continue to refuse and documenting each reapproach and interaction and identified that she was unsure why that had not been done. Review of the Medication Administration policy (undated) directed, in part, that all medications shall be administered safely and accurately in accordance with physician's orders, facility protocols and applicable state and federal regulations.

Document the administration in the MAR immediately after giving the medication. Monitor residents for therapeutic side effects and potential side effects of medications. All resident refusals of medication must be documented in the medical record, including the reason for refusal if provided, and the provider must be notified as appropriate. If medication is not available at the time of administration: notify the physician immediately and request guidance or an alternative order, inform he resident or their responsible party, check with the pharmacy to expedite delivery of the medication and document all actions taken in the resident's medical record and notify the supervisor.

Event ID:

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Apple Rehab West Haven

308 Savin Avenue West Haven, CT 06516

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for admission orders, the facility failed to ensure an appointment was scheduled with an outside specialty provider per admission orders. The findings include:Resident #1's diagnoses included Alzheimer's disease, type 2 diabetes mellitus and myotonic muscular dystrophy (a genetic disorder affecting the muscles and causing progressive weakness and muscle stiffness). The Nursing admission assessment dated [DATE REDACTED] at 7:33 PM identified that Resident #1 was alert with good memory recall and required staff assistance with positioning and transfers. The Resident Care Plan (RCP) dated 5/7/25 identified that Resident #1 has a diagnosis of diabetes and is at risk for hypo/hyperglycemia.

Interventions included watching for any acute signs/symptoms of hypo/hyperglycemia and reporting to the provider, checking the resident's blood sugar with any diabetic signs and symptoms including sweating, confusion or changes in mental status. A nurse's note dated 5/7/25 at 8:58 PM identified that Resident #1 was newly admitted to the facility at 4:00 PM and required an Endocrinology appointment within one (1) to two (2) weeks. A physician's order dated 5/7/25 directed that Resident #1 required a follow-up appointment with Endocrinology within 1 to 2 weeks and directed to discontinue the order when the appointment was obtained. Review of the clinical record from 5/8/25 through 8/23/25 failed to identify that an endocrinology appointment was ever scheduled or that the resident was seen by endocrinology. Review of the Medication Administration Records from May 2025 through August 2025 identified that nursing continued to sign off the 5/7/25 order identifying that Resident #1 required an endocrinology appointment daily at 9:00 AM until 8/22/25 (3.5 months later). Interview with Person #1 (Endocrinology office) on 9/17/25 at 11:18 AM identified that Resident #1 had not been seen in their office from May to August 2025 and reported that no one from the facility had ever called them to set up an appointment. Interview with Registered Nurse (RN) #5 (3:00 PM to 11:00 PM Nursing Supervisor) on 9/17/25 at 3:13 PM identified that when a resident is admitted to the facility with hospital paperwork stating they require an appointment with an outside provider,

she notifies the provider, notates it on the facility's 24-hour report and then enters an order that shows up

on the MAR so that the charge nurse is aware that they need to schedule the appointment. RN #5 identified that the charge nurse is responsible for scheduling the appointment within 72-hours and reported that if

they don't have time, it's their responsibility to notify the nursing supervisor for assistance. She identified that the endocrinology appointment should have been scheduled by the facility, and she was unsure why it had not been. Interview with the Director of Nursing (DON) on 9/17/25 at 2:41 PM identified that the facility doesn't utilize secretaries or unit managers, so the charge nurses and nursing supervisors are responsible for making appointments and setting up transportation for residents who require appointments outside of

the facility. She reported that although she was not the DON at the time of Resident #1's admission and she was unaware that the resident required an endocrinology appointment, nursing staff should have followed

the physician's order and ensured that the appointment was scheduled as directed and that coordination of medical care was preserved for the resident. The DON identified that staff should have scheduled the appointment within 48 to 72 hours, and she was unsure why staff continued signing off the order daily for three (3) months without scheduling the appointment. Although requested, policies on following physician's orders and scheduling offsite provider appointments were not provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Apple Rehab West Haven

308 Savin Avenue West Haven, CT 06516

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Interview with the Director of Nursing (DON) on 9/17/25 at 2:41 PM identified that nursing staff is responsible for documenting in the clinical record for a resident as close to the event that the care takes place but no later than the end of the shift. The DON reported that RN #2 should have documented Resident #1's body temperature and blood sugar in the clinical record on 8/23/25 and she was unaware that it had not been done. Review of the Nursing Documentation policy (undated) directed, in part, that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift. In extenuating circumstances, documentation may be entered at a later time, but it must be clearly indicated as such to maintain transparency and accuracy. All entries must be factual, complete, and reflect the resident's current condition and care provided. Document any changes in the resident's condition, new symptoms, or reactions to treatments immediately and include any actions taken (e.g., physician notification) and resident/family communication.

Event ID:

Facility ID:

If continuation sheet