Summerfield Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three staff (Unlicensed Staff A) used the proper personal protective equipment (PPE-protective clothing or other garments or equipment designed to protect the wearer's body from injury or infection) while caring for residents with confirmed diagnosis of COVID-19 (Coronavirus, an infectious disease caused by a virus). Unlicensed Staff A was in a room with two residents that had confirmed COVID-19 and wearing a surgical mask over her mouth that did not cover the nose. When Unlicensed Staff A adjusted the mask, the nose remained uncovered. This failure had the potential to cause Unlicensed Staff A to contract the virus, who in turn could have exposed other residents, staff and visitors to the infectious disease. [...]

Inspectors wroteBased on interview and record review, facility staff did not follow physician orders from 2/10/25 to 2/11/25, to ensure Sampled Resident #1 wore a wrist brace on her right wrist at all times. This failure had the potential for Resident #1 ' s right wrist fracture to heal in an incorrect position or for the broken bone pieces to not grow back together properly (Occurs with excessive movement or inadequate stabilization of the fracture site. When a bone is not able to heal properly it will take longer to heal and result in prolonged swelling, tenderness, and pain).

Inspectors wroteBased on observation, interview and record review, the facility failed to permit two of three sampled residents (Resident 1 and Resident 2) to remain in the facility (Facility 1), when the facility initiated and transferred Resident 1 and Resident 2 to other skilled nursing facilities (Facility 2 and Facility 3) without providing evidence that Resident 1 and Resident 2 ' s health had improved sufficiently so they no longer needed the services provided by the facility, which was the reason given for the transfers. This failure caused emotional distress for Resident 1 and had the potential for emotional distress for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nursing care plans to manage pain for two of four sampled residents (Resident 11 and Resident 109) were comprehensive (Covering completely or broadly), resident-centered, and contained specific pharmacological (Relating to medications) and non-pharmacological (Not involving medications) interventions to prevent pain, based on the residents' pain assessments. These findings had the potential to result in ineffective pain management interventions to control the residents' pain, which could have caused them suffering and distress.

Inspectors wroteBased on interviews and a review of facility documents, it was determined that the pharmacy consultant did not identify instances where patients received Polycarbophil in conjunction with other oral medications, contrary to the manufacturer's guidelines. These guidelines stipulate that Polycarbophil should be taken at least two hours before or after other medications. These errors occurred in three of three patients who received Polycarbophil alongside other medications.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, six medication errors were observed out of twenty-eight opportunities for three of three residents, resulting in an error rate of 21%.

Inspectors wroteBased on interviews and a review of facility records, it was discovered that the facility did not maintain proper temperature controls for medication storage during the months of December 2023 through February 2024. The medication refrigerator temperatures were found to be outside the acceptable range during this period, which is a critical requirement for ensuring the safety and efficacy of stored drugs. It was found that when the medication refrigerator was out of range, no direct actions were taken to address the temperature deviations. This lack of action further compromised the safety and effectiveness of the stored medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident food was stored safely, and staff were knowledgeable of sanitizing practices when: 1. A Kitchen Aid (Dietary Aid F) was not able to describe the three-compartment method for washing and sanitizing dishes during emergencies, and was unable to find the facility policy/procedure that explained the indications for this process, and; 2. The temperature in the dry storage room and emergency food storage room, where the facility stored food and drinks for residents, was not checked regularly, and the temperatures were not being recorded to verify that food was being stored at safe temperatures. These findings had the potential to result in food borne illnesses and infections to the residents of the facility and did not support safe practices during emergency situations.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not provide the necessary respiratory care consistent with resident's care plan for oxygen therapy and current physician's orders for one of two sampled residents, Resident 41, when he was observed receiving oxygen therapy via nasal cannula (A nasal cannula is a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) at 3.5 LPM (liters per minute). This failure had the potential to result in respiratory acidosis (A condition that occurs when your lungs can't remove all of the carbon dioxide produced by your body. This causes the blood and other body fluids to become too acidic) and may affect the health and well-being of Resident 41.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide pain management that met professional standards of practice, and pain management that was based on the comprehensive care plan of one of three sampled residents, Resident 151, when the facility did not have a physician's order indicated to address severe pain. This failure had the potential to result in ineffective pain management that could affect his well-being, his ability to perform activities of daily living, or his ability to participate in therapeutic physical exercises.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food preferences of one of four sampled residents (Resident 107) was honored when he was not served the alternate meal he had ordered for lunch. This finding caused Resident 107 frustration, and had the potential to result in malnutrition, weight loss, and feelings of helplessness for Resident 107.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four trash cans in the kitchen were completely covered when not in use. These trash cans had large circular holes measuring approximately 12 inches in diameter that had been cut out in their lids, which made it convenient for the staff to discard garbage without removing the lid, but kept the trash exposed and open to air at all times. This finding had the potential to result in development and growth of pests such as insects and rodents, foul odors in the kitchen and the spread of pathogenic microorganisms (bacteria or viruses capable of producing disease), which could have caused infections and diseases to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical documentation for one of four sampled residents (Resident 11) was complete and accurate, when a physician's order to recheck Resident 11's glucose (BG-Blood sugar) level was not documented in the medical record as completed. As a result, there was no way to verify that this physician order was carried out as written, which could have resulted in serious diabetic (Referring to Diabetes Mellitus-A chronic disease characterized by high levels of blood sugar) complications for Resident 11. This finding also had the potential to result in in clinical documentation that did not reflect the resident's condition and the care and services provided across all disciplines to ensure information was available to facilitate communication among the interdisciplinary team.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure that 2 of 2 refrigerated vaccines (Influenza and Pneumococcal) were stored at the temperature required to maintain their overall safety and effectiveness. This had the potential to reduce the effectiveness of vaccines stored at the facility for administration to residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a medication error rate below 5%, when the manufacturer specifications for administration of medication for 2 of 25 medications administered during an observed medication pass was not followed. This failure resulted in a 8% medication error rate, and had the potential to result in administration of subtherapeutic (e.g., lower than that prescribed to treat a disease effectively) doses of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices for two residents (Resident 21 and Resident 16) when: 1. Licensed Staff did not perform proper hand hygiene during wound care. 2. Facility staff placed a meal tray for lunch on an unsanitized bedside table with a quarter-filled urinal on it. These failures created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in serious illness.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assess 2 of 12 sampled residents' (Resident 7 and Resident 39) ability to self-administer medications when the facility did not: 1. Assess the ability of Resident 7, who had a right-sided impairment due to stroke and was permitted to self-administer his own eye drops. 2. Re-assess the ability of Resident 39, following Resident 39's development of visual and cognitive impairments. This failure had the potential to negatively affect eye health for Resident 7 and Resident 39.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care and service in accordance with professional scope of practice to one resident (Resident 149) who received oxygen therapy. This failure resulted in unlicensed staff working outside their scope of practice, and had the potential to result in Resident 149 receiving an inappropriate amount of oxygen.