Summer Commons

Inspectors wroteBased on record review and interviews, the facility failed to assess and monitor a resident after a fall and failed to follow their own Fall management and Neurological evaluation policies and procedures by obtaining neurological assessments for residents who had unwitnessed falls for 3 of 6 residents reviewed for falls. (Resident #9, #23, #71) The facilities Falls Management Policy last updated 2/2025 states under procedure; A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. Complete Post Fall Observation Tool, following a fall, to identify if the cause of the fall is related to mental status changes, physical limitations or environment factors. A neurological assessment tool will be initiated for falls where there is a known head bump. [...]

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 2 medication storage rooms observed (August Unit). On 8/26/25 at 9:15 a.m. a surveyor observed the [NAME] Unit medication room with the Registered Nurse Manager. The refrigerator contained an opened and undated multidose vial of Tuberculin Purified Protein Derivative (TB) with the following manufacturer's instructions of, Once entered, vial should be discarded after 30 days. At this time, the Registered Nurse Manager confirmed the above and discarded the TB vial.

Inspectors wroteBased on record review and observation the facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to hand hygiene during medication administration for 1 of 4 residents observed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the physician was notified of a wound culture and sensitivity (C&S) result when organisms were identified that were resistant to the antibiotic already ordered, for 1 of 1 residents reviewed for non-pressure related skin conditions (#52). A review of the facility's policies and procedures for Antibiotic Stewardship stated 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 12. When a culture and sensitivity (C&S) is ordered, lab results are received, and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. And, Antibiotic Stewardship - Orders for Antibiotics stated, 3. Appropriate indications for use of antibiotics include: [...]

Inspectors wroteBased on interviews, record reviews and observations the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident after each Minimum Data Set (MDS) 3.0 assessment for 2 of 18 residents (Resident #34 and #32), and failed to ensure a care plan was updated to reflect the current needs in the areas of falls and self-care deficit (Resident #43), and communication (Resident #6) for 4 of 18 residents whose care plans were reviewed.

Inspectors wroteBased on interview and review of the facility's Quality Assurance and Performance Improvement (QAPI) program, the facility failed to present evidence that the required members attended 3 of 4 quarters provided (January 2025, April 2025, and July 2025). On 8/27/25, a surveyor reviewed attendance sheets for the QAPI quarterly meetings. A review of the January 2025 QAPI attendance sheet lacked evidence that the Medical Director attended the meeting. The April 2025 QAPI attendance sheet lacked evidence that the Infection Preventionist attended the meeting. The July 2025 QAPI attendance sheet lacked evidence that the Director of Nursing attended the meeting. On 8/27/25 at 3:30 p.m., in a discussion with a surveyor, the Administrator confirmed the finding.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week on 5 of 62 days (December 2023 and January 2024) reviewed for RN coverage.

Inspectors wroteBased on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 33 opportunities.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that medications were stored properly by having unattended medication cards on top of the cart allowing residents and unauthorized persons access to them on 1 of 3 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 2 of 2 medication rooms (July and August).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was labeled and dated in the refrigerator for 2 of 3 days of survey. In addition, the facility failed to monitor refrigerator/freezer temperatures and sanitizer bucket part per million (ppm) daily.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to oxygen tubing, bed pans and commodes for 3 of 3 days of survey and failed to prevent the possible transmissions of infections by handling medications and administering injection and eye drops with ungloved hands during medication administration for 2 of 2 medication pass observations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare instructions necessary to properly care for the resident and failed to ensure that a resident, and/or resident representative, was provided a summary of the care plan for 2 of 3 residents sampled for new admissions (#44 & #113).

Inspectors wroteBased on observations, record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of 1 of 2 residents reviewed for respiratory. (#52)

Inspectors wroteBased on observation, record review and interview, the facility failed to follow their own policy on oxygen (O2) storage and failed to obtain physician orders for oxygen therapy for 1 of 2 residents reviewed for respiratory care. (#52)

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed (prn) psychotropic medication order met the required 14-day time limit or provided the rationale to extend the time limit beyond the 14 days, with the indicated duration, for 1 of 2 residents reviewed for pain management (Resident #51).

Inspectors wroteBased on observations, interviews and lunch meal test trays, the facility failed to serve hot foods for 1 of 2 lunch meals tested for appetizing temperatures.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that 3 of 5 residents reviewed for immunizations received pneumococcal vaccinations (Residents #20, #38 and #41).

Inspectors wroteBased on record reviews and interviews the facility failed to ensure as needed (PRN) psychotropic medications met the required 14-day limit for 1 of 6 residents reviewed for unnecessary medications (Resident #5).