New Summit Rehabilitation and Healthcare

Inspectors wroteBased on interviews, and record review, the facility failed to create and implement/follow a comprehensive care plan to ensure resident safety. This failure affected two residents (R1 and R3) of three (R1, R2, and R3) in the sample. In one instance, a Certified Nursing Assistant failed to follow the care plan interventions requiring continuous supervision/ total assistance during care for R3, resulting in R3 being left unattended and, subsequently, falling to the floor. Also, R1's care plan is not reflective of the Director of Nursing and staff's verbalization/nursing judgement that R1 is best transferred with two staff members present. This failure resulted in a fall with injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prevent a resident from falling, resulting in a fall with injury and failed to keep another resident free from falls while rehabilitating with two current fractures. These failures affected two (R1 and R3) of three residents (R1, R2, and R3) reviewed for falls. This failure caused R3 to fall while being left alone to perform a personal hygiene task, instead of being supervised for the entire activity of daily living task and failed to prevent R1 from falling due to lack of appropriate care planning which resulted in an injury for R1. These failures have the potential to affect any resident who is a fall risk and any resident requiring total assistance/observance with their activities of daily living tasks.

Inspectors wroteBased on observation, interview and record review the facility failed to have fall interventions in place for a resident at risk for fall and failed to ensure a resident was transferred safely for 2 of 20 residents (R33 and R36) reviewed for safety and supervision in the sample of 20. This failure resulted in R36 falling and sustaining a right ankle fracture that required surgical repair.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a cervical neck collar and ace wraps were in place as ordered, failed to clarify physician prescribed medication orders to ensure a resident received the medications and failed to perform an assessment immediately after and following a fall for 4 of 20 residents (R36, R52, R47 and R299) reviewed for quality of care in the sample of 20.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident refrigerators were monitored and maintained, and failed to ensure perishable foods were dated which applies to 7 of 7 residents (R33, R55, R67, R65, R298, R199, R80) reviewed for safe food handling in a sample of 20.

Inspectors wrote4. On 6/9/25 at 11:35 AM, R36 was lying in bed. R36 said that she is getting treatment for the wounds on her buttock. R36's room door did not have a sign on it saying she was on EBP (Enhanced Barrier Precautions) nor was there PPE (Personal Protective Equipment) outside of R36's room. On 6/9/25 at 11:37 AM, V7 (Infection Preventionist) put an EBP sign on R36's door and a cart of PPE outside of the door. On 6/9/25 at 2:25 PM, V7 said that she did just put R36's EBP sign on her door that day. V7 said that she was reviewing charts and noticed that R36 came back from the hospital with multiple wounds and should have been placed on EBP upon her re-admission. R36's Physician's Order Sheet printed on 6/9/25 shows that she re-admitted to the facility on [DATE] and an order for EBP for wounds was placed on 6/9/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's assessment was completed accurately for 1 of 20 residents (R95) reviewed for assessments in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had a dressing on a pressure injury and failed to ensure pressure prevention interventions were in place for 2 of 6 residents (R47, R299) reviewed for pressure injuries in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure indwelling urinary catheter bags were kept below the level of the bladder and off of the floor to prevent infections for 2 of 3 residents (R148 and R47) reviewed for indwelling urinary catheters in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor residents to ensure medications were administered completely which applies to 2 of 2 residents (R1, R4) reviewed for medication administration in a sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was within reach for a high fall risk resident which applies to 1 or 6 residents (R1) reviewed for safety in a sample of 16.

Inspectors wroteBased on interview and record review the facility failed to ensure treatment orders were performed for a resident with a stage 3 sacral pressure injury. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate Enhanced Barrier Precautions (EBP) for residents with an increased risk of contracting a Multi-drug Resistant Organism (MDRO) during high contact activities for 8 of 10 residents (R198, R292, R22, R287, R190, R301, R203, R291) reviewed for infection control in the sample of 14 and 7 residents (R29, R202, R30, R294, R204, R200, R201) outside the sample.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received showers for 1 of 1 resident (R203) reviewed for activities of daily living in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician ordered dressing was in place for a resident at risk for skin breakdown for 1 of 3 residents (R203) reviewed for pressure ulcers in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a drainage bag was not laying on the bed, was kept below the level of the bladder, and a dignity bag was used to cover the drainage bag. The facility failed to ensure catheter tubing was not kinked or occluded. This applies to 3 of 3 residents (R287, R22, R190) reviewed for catheters in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate for 1 of 1 resident (R192) reviewed for oxygen in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor a resident's food preference and find an appropriate alternative for 1 of 1 resident (R300) reviewed for food preferences in the sample of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to assess a resident's skin condition for 1 of 3 residents (R1) reviewed for non pressure skin condition in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed ensure staff wore hairnets in the kitchen. The facility failed to store dry foods in a manner to prevent contamination. The facility failed to sanitize/wash dishware in a manner to prevent cross contamination. The facility failed to ensure food storage areas were clean and free of debris. These failures have the potential to affect all 35 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a COVID positive staff member did not provide cares to facility residents. The facility failed to ensure staff wore the recommended personal protective equipment (PPE) when caring for COVID positive residents and during facility testing for COVID-19. These failures have the potential to affect all 35 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the recipes, to ensure the nutritive value of pureed foods, for four of four residents (R18, R25, R28, R197) reviewed for pureed diets in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to monitor residents' weight that have a history of weight changes for two of three residents (R28, R25) reviewed for weight change in the sample of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 29 opportunities with 5 errors resulting in a 17.24% error rate.