Signature Healthcare at Summerfield Rehab & Wellne

Inspectors wroteBased on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident or the resident's representative received adequate notice before transfer or discharge for four out of five residents (Resident (R) 3, R4, R13, and R14). The facility initiated a transfer/discharge based on the facility's inability to meet the resident's needs. However, upon complaint investigation, it was determined by interview and record review that the transfer/discharge was due to the facility needing to move the residents out of their rooms to make space for a new rehabilitation unit. Residents 3, R4, and R13 were selected based on their least likely to have a connection with the community. The residents were provided a notice of transfer/discharge on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one for 30 sampled residents, Resident (R) 1. R1 sustained a fall between 04/16/2024 and 04/18/2024. Interviews and record review revealed staff failed to follow the resident's care plan which instructed staff to utilize the mechanical lift when transferring the resident from her bed to wheelchair. An unknown staff member transferred the resident without utilizing the resident's mechanical lift and the resident fell on her knees, resulting in a fracture of the distal right femur (broken thigh bone near the knee).

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of medication package inserts, and review of the facility's policy, the facility failed to ensure appropriate environmental controls were used to preserve their integrity in one of two medication refrigerators. Additionally, the facility failed to ensure drugs and biologicals were stored per currently accepted professional principles for six of 96 residents (Residents (R) 7, R8, R9, R10, R27, and R28). Observation on 09/04/2024, revealed one opened and undated vial of purified protein derivative (PPD), (used in a tuberculin skin test for tuberculosis) was found in the [NAME] Unit medication refrigerator. On 09/04/2024, during an observation of the medication cart on the 700 Hall, it was noted that multiple eye drops and insulin vials were not dated when opened. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies and review of the contracted company's policies and documents it was determined the facility failed to store food in the residents' refrigerator in a safe and sanitary manner. This affected 25 of 96 current residents. Observation of [NAME] Unit's resident food freezer on 09/04/2024 revealed there was no thermometer in the freezer. An unfrozen ice gel pack was observed in the freezer. Additionally, multiple frozen food boxes were stored inside grocery bags, and were unlabeled and undated. The boxes of food were not frozen solid. The freezer compartment floor was dirty with melted liquid, packaging debris, dirt, food particles, and hair.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined 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 and control the development and transmission of communicable diseases affecting five of 96 Residents (Resident 5 (R5), R17, R18, R21, R23). Observation on 09/04/2024 revealed the doors to two droplet precaution isolation rooms, rooms [ROOM NUMBERS], remained open. The trash can inside R17 and R18's room, was overflowing with contaminated personal protective equipment (PPE). [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's fact sheet Preventing the Spread of Bloodborne Pathogens, review of the facility's online education course outline, Bloodborne Pathogens and the Use of Standard Precautions, review of Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, Microdot (brand) bleach wipes manufacturer's instructions, Cleaning and Disinfecting Recommendations,'; review of the facility's internal resource Common Infections, PPE & Isolation Guidelines,; review of the CDC's Enhanced Barrier Precaution (EBP) door signage, and review of the facility's policies, it was determined the facility failed to implement recommended interventions for the cleaning and disinfecting of a shared glucometer (glucose monitoring device), according to manufacturer's instructions. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs for nine (9) of seventy-one (71) sampled residents (Residents #1, #4, #11, #39, #41, #48, #59, #325, and #381). Resident #59's care plan had interventions to provide incontinence care, which staff failed to implement causing emotional distress. Resident #41's care plan had interventions for falls. However, observations revealed these interventions were not implemented. Resident #381 was identified as a fall risk with an intervention placed in the care plan but not implemented. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's job descriptions, and review of the facility's policy, it was determined the facility failed to provide necessary services to a resident who was incapable of carrying out activities of daily living to maintain personal hygiene for one (1) of seventy-one (71) sampled residents (Resident #59). Resident #59 was dependent on staff to perform toileting hygiene; staff failed to change Resident #59's briefs timely resulting in the resident experiencing emotional distress, crying because he/she was left laying in a bed soaked with urine.

Inspectors wroteBased on observation, interview, and review of the facility's policies, it was determined the facility failed to store and prepare food under sanitary conditions. Observation on 01/22/2024 on the initial kitchen tour revealed ingredient containers not dated; and scoops, a set of solid stainless steel bowls, and a strainer stored sitting up. Continued observation during the supper meal service revealed no hand washing between glove changes, and a staff member patted the surface of the plate into the plate holder using a bare hand.

Inspectors wroteBased on observation, interview, record review and review of the facility's assessment, it was determined the facility failed to ensure the Facility Assessment was clear on evaluating its resident population; identifying the resources needed; and the level of staffing for each unit, to provide the necessary care and services to match the acuity level of the community.

Inspectors wroteBased on observation, interview and review of facility policy it was determined the facility failed to provide a safe, clean, comfortable and homelike environment for five (5) of seventy-one (71) sampled residents, (Residents #44, #55, #60, #65, and #88). Observations during the survey revealed a continuous odor of urine on the 100 Unit. During interview with Resident #44, he/she stated that he/she kept the door closed to cut down on the odor; however, he/she could smell the odor when the door opened. During interview with Resident #55, he/she stated he/she moved quickly down the hallway to avoid the odor. Observation revealed Resident #60 had excessive accumulation of dead skin under the books and puzzles pieces on the bedside table and excessive dead skin under the foot of the bed. Observation revealed soiled/stained linens on Residents #65's and #88's beds. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for five (5) of seventy-one (71) sampled residents (Residents #1, #8, #11, #324, and #381). Resident #11 received oxygen (O2) without a Physician's Order. Additionally, Residents #1, #8, #11, and #381 had O2 tubing that was not labeled nor dated. Furthermore, Resident #324's nebulizer machine was not stored in a plastic bag when not in use.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that medications were stored in proper temperatures and other appropriate environmental controls to preserve their integrity for two (2) of two (2) refrigerators. Additionally, it was determined the facility failed to ensure opened and in-use vials of tuberculin skin test (TST) solution, eye drops, and inhalers were not expired, on three (3) of five (5) medication carts.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for three (3) of seventy-one (71) sampled residents (Residents #1, #11, and # 324). Resident #324 stated he/she was not incontinent, but staff told the resident to use a brief, causing Resident #324 to sit in his/her own feces and urine until assisted. Resident #1 had a severe hearing impairment. He/she had a caption phone in his/her room that had not been functional for an unknown amount of time. The facility was made aware by the resident, but failed to ensure the resident had an effective means of communication. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to honor the resident's right to self-determination as related to choosing his/her daily schedule for one (1) of seventy-one (71) sampled residents (Resident #4). The facility failed to get Resident #4 out of bed timely in the morning according to his/her preferences.

Inspectors wroteBased on interview and record review, it was determined the facility failed to notify the Power of Attorney (POA) of a fall and transfer to the hospital for one (1) of seventy-one (71) sampled residents (Resident #326).

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of seventy-one (71) sampled residents (Residents #41 and #381). 1. Resident #381 sustained a fall on 01/18/2024; however, the facility failed to develop and implement new interventions to address the resident's safety and prevention of further falls. Resident #381's Comprehensive Care Plan was revised after the fall on 01/18/2024 to place Dycem (a nonslip material used to help stabilize/hold objects firmly in place in a resident's wheelchair); however, this intervention was not implemented by facility staff. 2. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary hydration needs for two (2) of seventy-one (71) sampled residents, (Resident #48 and Resident #39). Review of Resident #48's Nutrition Therapy Evaluation completed by the Registered Dietitian (RD) on 08/16/2023 revealed the facility assessed the resident to require 1950 milliliters (ml) daily for his/her fluid intake. The Nutrition Evaluation completed by the RD on 10/03/2023 revealed the facility assessed Resident #48 to require 2030 ml/daily for fluid intake. However, review of Resident #48's fluid intake log for October, November, and December 2023 and January 2024, revealed those daily needs were not met. The facility failed to document any refusals by Resident #48 to account for a reason the need was not met. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was administered as needed and as ordered to the resident per the Physician's Orders, the Comprehensive Care Plan, and the goals and preferences for one (1) of seventy-one (71) sampled residents (Resident #325).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined 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 two (2) out of seventy-one (71) sampled residents (Residents #11 and #17). During medication pass observations, the facility failed to have magnesium 400 milligrams (mg) available for Resident #11. Furthermore, the facility failed to have polyethylene glycol 17 grams (Miralax) and a lidocaine 5% patch available for Resident #17.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to obtain the resident's needs, preferences, and religious, cultural, and ethnic needs for one (1) of seventy-one (71) sampled residents, (Residents #325).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide palatable hot and cold food for four (4) of one of seventy-one (71) sampled, (Residents #8, #12, #38, and #88). In addition, observation of the test tray on 01/27/2024 revealed the hot food tested colder and cold beverages tested warmer than the required temperatures. The cooked oatmeal cereal had a watery consistency.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to have resident funds available for two (2) of two (2) of twenty-six (26) sampled residents, Resident #128, and Resident #112. Resident #128 had money deposited into the personal fund account and he/she was not able to access the money for up to three (3) days on some occasions. Resident #112 requested thirty dollars ($30.00) from his/her personal fund and was only allowed to have twenty-four dollars ($24.00).

Inspectors wroteBased on record review, interview and facility policy review it was determined the facility failed to transmit discharge data for two (2) of two (2) discharged residents, Residents #1 and #2.

Inspectors wroteBased on observation, interview, record and policy review it was determined the facility failed to keep one (1) supply room door closed and locked for one (1) of two (2) supply rooms. The blue unit supply room was noted to be unlocked and did not close. Further observation of the supply room revealed mouthwash, shaving cream, toothpaste, baby lotion, bye bye odor cleaner, roll on antiperspirant, and siobiotext on the shelves in the room.

Inspectors wroteBased on observation, interview, record review and facility policy review, it was determined the facility failed to ensure staff provided assistance with care to ensure transportation to scheduled dialysis was not missed for one (1) of two (2) of twenty-six (26) sampled residents, Resident #186.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to insure medications were securely stored to prevent resident access for one (1) of twenty-six (26) sampled residents, Resident #101. Observations revealed a Lantus insulin pen left unattended on the resident's over bed table.

Inspectors wroteBased on observation, interview and review of facility policy, it was determined the facility failed to ensure staff were documenting dishmachine water temperatures and the concentration of the sanitizing solution in parts per million (ppm).