Focused Care at Summer Place

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated and labeled appropriately. 2. The facility failed to discard food stored in the refrigerator that should no longer be consumed. These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eleven residents reviewed for quality of care. The facility failed to thoroughly document measurements of two skin openings on Resident #1's bilateral (both sides) buttocks and notify the MD or NP regarding two skin openings that were present on admission. This failure could place residents at risk of not receiving necessary medical care and deterioration of the skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 24 residents (Residents #27, #8 and #23) reviewed for nutrition. 1. The facility did not ensure dietary recommendations was implemented for Resident #27. 2. The facility failed to ensure orders for fortified oatmeal was implemented for Resident #8. 3. The facility failed to ensure Resident #23 had water in his cup to drink on 08/25/25. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu according to 2 of 3 resident councils and 1 of 1 meal (the lunch meal) reviewed. 1. The facility failed to follow the menu for the lunch meal served on 08/25/25. 2. The facility failed to serve what was printed on the residents' tray cards or posted in the kitchen as mentioned in resident council meetings held on 06/03/25 and 08/26/25. These failures could place residents who consume food prepared by the facility's kitchen at risk of not having their nutritional needs met and/or experiencing weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 23 residents (Resident #67 and Resident #87) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide food that was palatable and attractive to Resident #67 and Resident # 87, who complained the food was not good, cold, hard, and overcooked. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 infections for 2 of 4 residents (Residents #30 and Resident #65) and 1 of 3 halls (Hall 100) reviewed for infection control practices. 1. The facility failed to ensure CNA O performed proper hand hygiene and glove changes when providing incontinent care to Resident #30 on 08/25/2025. 2. The facility failed to ensure the Maintenance Supervisor wore PPE when entering Resident #65's room on 08/27/25, who was on contact isolation for C. diff (a highly contagious bacterium that causes diarrhea). The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #65's isolation room with C. diff. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #87) reviewed for reasonable accommodations. The facility failed to ensure Resident #87's call light was within reach while in bed on 08/25/2025. This failure could place residents at risk for a delay in assistance and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident mail was delivered promptly and unopened for 1 of 10 residents (Resident #62) reviewed for communication. The facility failed to ensure that mail was delivered to Resident #62 unopened. This failure could place residents at risk of not receiving mail in a prompt and private manner and could result in a loss of personal property, frustration, and loss of dignity for the residents who reside at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #9). The facility failed to ensure Resident #9's PRN Ativan (antianxiety medication) was discontinued within 14 days or reevaluated by the prescribing practitioner. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 1 resident (Resident #94) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #94's discharge MDS assessment dated [DATE] reflected Resident #94 was discharged to a short-term general hospital when the resident was discharged home. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #99) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #99's use of a wound VAC (machine that promotes wound healing by applying negative pressure to the wound area by helping to draw the edges together and remove excess fluid) to her right thigh wound. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 24 residents (Resident #8 and Resident #9) reviewed for care plans. 1. The facility failed to ensure Resident #8's care plan included her fall on 04/03/25 and interventions.2. The facility failed to ensure Resident #9's care plan included the antianxiety medication prescribed for her anxiety. These failures could have placed residents at risk for not having their needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 24 residents (Residents #63) reviewed for ADL care. The facility failed to ensure Resident #63 was assisted with her personal hygiene to ensure she was free of body odor and had a clean gown on 08/25/2025. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 (Resident #99) residents reviewed for quality of care. The facility failed to ensure Resident #99's wound treatment to her right posterior thigh was performed on 08/22/2025. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and wound deterioration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #67) reviewed for respiratory care. The facility failed to ensure Resident #67's oxygen was set at 3 liters per nasal cannula as ordered on 08/28/25. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 2 resident reviewed for dialysis services. (Resident #7) The facility did not provide ongoing assessments after Resident #7's dialysis treatments and did not keep ongoing communication with the dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #91) and 1 of 2 medication rooms reviewed for pharmacy services. 1. The facility failed to reorder Resident #91's hydrocodone 7.5/325mg (pain medication) tablet timely resulting in Resident #91 having 3 days without medication. 2. The facility did not ensure the plastic bag of Lorazepam 2mg/ml (antianxiety medication) syringes in the station 2 refrigerator we reconciled. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 24 residents (Resident #23) and 1 of 10 medication carts (Station 1 Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure MA P secured the Station 1 Medication Cart, when it was not in use and unattended on 08/25/2025. 2. The facility failed to ensure Resident #23 did not have a container of zinc oxide, a package of hydrocortisone cream, and a 30-milliliter medicine cup filled with white cream in his room on the bedside table. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed ensure each resident received and the facility provides food that accommodates residents' food preferences for 1 of 24 residents (Resident #6) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #6's preference for fruit punch on 08/25/25 and 08/26/25. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent with the resident's needs for 1 of 23 (Resident #83) residents reviewed for liquid inconsistency. The facility did not ensure that staff served Resident #83 her 8-ounce water during her lunch meal on 08/26/25. This failure could place residents at risk for dehydration and loss of interest in eating.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to maintain proper kitchen sanitation when [NAME] D went outside the kitchen and returned without proper hand hygiene protocols. This deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 5 residents (Residents #'s 4 and 12) reviewed for hospice services. 1. The facility failed to obtain Resident #4's most recent updated hospice plan of care. 2. The facility failed to ensure Resident #12's hospice records were a part of their records in the facility. These deficient practices could place residents at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements.1. The facility failed to ensure spoiled strawberries were not stored in the walk-in cooler. 2. The facility failed to ensure raw meat was not stored on top of ready to eat green apples in the walk-in cooler. 3. The facility failed to ensure food items in the freezer #1, #2 and dry pantry were labeled, dated and sealed. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistive devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a mechanical lift and had assistance from another staff member during a bed to wheelchair transfer on 05/05/25 which resulted in Resident #1 having complaint of pain to the right ankle. An x-ray was conducted on 05/05/25 with the results of evidence of acute fracture of the right distal tibia (bone in the lower leg). The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 05/05/25 and ended on 05/07/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for 1 of 5 residents (Resident #2) reviewed for personal property. LVN B took Resident #2's personal cell phone away from her on 11/9/2024 and it was out of Resident #2's possession until the next shift arrived. This failure could place residents at risk of being deprived of their ability to use personal cell phone.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of possible injury of unknown origin or neglect immediately, but no later 2 hours after the allegation is made if the events that caused the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse to the State Agency in accordance with State law for 1 of 5 residents (Resident #1) reviewed for incidents. The facility failed to report to State Agency when Resident #1 was located in the visitor bathroom, deceased and a possible head injury, on [DATE]. This failure to report could place the residents at risk for unreported allegations of neglect and injuries of unknow origin not being investigated due to not reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen. The facility did not ensure the oatmeal and bread served for breakfast on 07/30/24 was palatable and the oatmeal recipe was followed. The facility did not ensure the Spanish rice served at the noon meal on 7/30/24 was palatable and the recipe was followed. These failures could place the residents at risk of a decline in their satisfaction and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food prepared in a form designed to meet individual needs of each resident for 1 of 1 kitchen. The facility did not ensure the pureed oatmeal and bread served for breakfast on 07/30/24 was in the correct food form. This failure could place the residents at risk of choking.

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 and to help prevent the development and transmission of communicable diseases and infections for 3 of 19 residents (Residents #47, #51, & #70) reviewed for incontinent care. CNA E and CNA F did not sanitize/wash their hands between glove changes before, during, and after incontinent care for Residents #47 & #51. CNA H did not change gloves, sanitize/wash her hands between glove changes, touched clean items with dirty gloves, and did not completely clean Resident #70 when providing incontinent care. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 19 residents reviewed for assessments. (Resident #70). The facility failed to complete an accurate resident assessment for Resident #70. Resident #70's resident assessment did not reflect that she received an antidepressant medication. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 19 residents reviewed for care plans. (Residents #59 and #70) The facility did not have a care plan to address Resident #59's nausea and vomiting. The facility did not have a care plan to address Resident #70's incontinence of bowel and bladder. This failureThe failures could place residents at risk of not having individual needs met and not receiving needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents reviewed for respiratory care and services. (Resident #292) The facility failed to administer BIPAP (a machine that can help people breathe when they have trouble breathing due to health issues) therapy as ordered by the physician for Resident #292. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for 1 of 19 residents reviewed for physician services. (Resident #59) LVN D notified the on-call NP of Resident #59 having nausea and vomiting and the on-call NP did not provide an order for the resident's need. This failure could place residents at risk of not having individual immediate needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents reviewed for medication administration. (Resident #59) LVN D did not administer prn nausea medication ordered for Resident #59 when she requested the medication. This failure could place residents at risk for not receiving the desired therapeutic effects of medications and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 3 of 3 medications reviewed for security. The facility did not ensure Plavix (antiplatelet), Lasix (medication used to remove fluid from the body), and Lexapro (antidepressant) were stored securely when the medications were left unattended at the nursing station. This failure could place residents at risk of harm by misappropriation of property and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 1 of 3 residents reviewed for MDS assessments. (Resident #70) The facility failed to transmit to the CMS system Resident #70's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required.