Apple Rehab Coccomo

In the surveyor’s words

From the most serious findings on record at Apple Rehab Coccomo, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 14, 2025

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of eight residents (Resident #1) reviewed for accidents, the facility failed to ensure staff supervision was conducted timely to identify a missing resident's whereabouts, failed to act timely when a resident was identified to be missing, and failed to follow their own policy and continue to search for a missing resident whose whereabouts were unknown for approximately six hours. The facility was later notified the resident was found waist deep in an icy pond. The failures resulted in a finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses included metabolic encephalopathy, dementia, depression, and anxiety disorder, and a history of alcohol abuse. […]

• No harm, potential for more than minimal, widespreadF725Aug 4, 2025

  Based on interviews and review of the Payroll Based Journal (PBJ) submissions, the facility failed to provide the appropriate number of weekend staff for Quarter 3 and Quarter 4 of Fiscal Year 2024 (April 1, 2024 through September 30, 2024) and Quarter 1 and Quarter 2 of Fiscal Year 2025 (October 1, 2024, through March 31, 2025). The findings include:PBJ submissions for Quarter 3 and Quarter 4 of Fiscal Year 2024 and Quarter 1 and Quarter 2 of Fiscal Year 2025 (April 1, 2024, through March 31, 2025) indicated the facility had triggered for excessively low weekend staffing.Interview and review of documentation with the Director of Nursing (DNS) on 8/1/25 at 3:37 PM identified that although she was not working at the facility for most of the time the PBJ submissions had triggered for… […]

• No harm, potential for more than minimal, patternF554Aug 4, 2025

  Based on observations, interviews, review of the clinical record, and facility policy for 1 of 1 sampled residents identified to self administer medication (Resident #45), the facility failed to assess Resident #45's ability to safely self-administer Insulin. The findings include: Resident #45's was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. An Inter-Agency Referral form (W-10) from the hospital and dated 2/26/25, indicated Resident #45 was ordered Humulin R U-500 KwikPen (an intermediate acting insulin to lower blood glucose), 25 units at breakfast, and 40 units at lunch, and 55 units at dinner. […]

• No harm, potential for more than minimal, patternF606Aug 4, 2025

  Based on interviews, review of employee personnel records and facility policy and interviews for 4 of 5 employees (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #3, Nurse Aide (NA) #3 and NA #9), the facility failed to ensure pre-employment references were obtained. The findings include:1. RN #1's date of hire was 9/7/23. No pre-employment references were obtained or located in the employee's personnel file. Although requested, the facility could not provide pre-employment references for RN #1. Review of the facility staffing schedules and time records indicated RN #1 currently worked at the facility. 2. LPN #3's date of hire was 10/3/24. No pre-employment references were identified in the employee's personnel file. […]

• No harm, potential for more than minimal, patternF656Aug 4, 2025

  Based on clinical record review, facility documentation, interviews, and facility policy for 1 of 4 sampled residents (Resident #3) reviewed for accidents, the facility failed to ensure a call bell was in reach per the Resident Care Plan (RCP) which resulted in a fall and for 1 of 2 sampled residents (Resident #84) reviewed for position/mobility and respiratory care, the facility failed to ensure the care plan was comprehensive to include a diagnoses with interventions for quadriplegia and respiratory care. The findings include: 1.Resident #3's diagnoses included Parkinson's disease, orthostatic hypotension, and a history of falling. The Resident Care Plan (RCP) dated 6/5/25 identified Resident #3 was a fall risk and required assistance with activities of daily living. […]