Summerford Health and Rehab, LLC

Inspectors wroteBased on record reviews, interviews, the facility's incident report, the facility's investigation titled, INVESTIGATION TEMPLATE, and the facility's policy titled, Abuse Prevention Program, the facility failed to protect Resident #403's right to be free from physical abuse by having inadequate staff to supervise residents. On 01/09/2023 at approximately 3:45 AM, Certified Nurse Assistant (CNA) #32 responded to Resident #403's room and observed him/her lying in bed with blood coming from a laceration to the face. Upon investigation, it was determined that residents were left unsupervised on the secured (locked) unit and staff failed to prevent Resident #404 from repeatedly striking Resident #403 with his/her cane. [...]

Inspectors wroteBased on record reviews, interviews, document reviews, and policy review, the facility failed to ensure sufficient staff were available to provide supervision for residents on the facility's secured unit during the night shift. On 01/09/2023 at approximately 2:30 AM, staff left residents on the [NAME] Haven Unit (a locked, secured unit where 24 residents resided) unsupervised to take care of residents on other units because there was an insufficient number of staff. While the locked/secured unit was unsupervised, Resident #404 struck their roommate, Resident #403, with a cane which resulted in a facial laceration, facial bruising and swelling, and multiple other injuries to the resident's body. This failure affected one of nine units in the facility.

Inspectors wroteBased on observation, interview, and facility policy and document review, the facility failed to ensure staff appropriately used and discarded personal protective equipment (PPE) for three (Residents #308, #38, and #47) of three residents reviewed who had transmission-based precautions implemented. These residents lived on three of six halls where residents resided. Resident #308 tested positive for coronavirus disease 2019 (COVID-19) and required contact and droplet precautions. Resident #38 and Resident #47 were identified as requiring enhanced barrier precautions.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to update the care plan to include interventions related to Resident #116's refusal of insulin administration. This failure affected one of 30 residents whose care plans were reviewed.

Inspectors wroteBased on observations, interviews, record review, and facility document and policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) that were necessary to maintain good grooming and personal hygiene for Resident #39. Specifically, Resident #39 had fingernails that were long and dirty. This failure affected one of 11 sampled residents reviewed for ADL care.

Inspectors wroteBased on observations, record review, interviews, and facility document and policy review, the facility failed to consider all causal factors related to falls when determining appropriate interventions to prevent further falls Resident #38. In addition, the facility failed to ensure staff implemented care planned interventions, including a fall mat and non-skid strips, on 07/17/2023 when the resident sustained a fall without injury. During the survey, Resident #38 was observed with no fall mat by their bed and no non-skid strips on the floor as specified by their care plan. This was observed on three of six days of survey. This affected one of three sampled residents reviewed for falls.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide physician ordered nutritional supplements Resident #76, one of two residents reviewed who had weight loss and physician orders for nutritional supplements.

Inspectors wroteBased on interviews, record reviews, facility policy and document review, the facility failed to ensure a Certified Nursing Assistant (CNA) reported an allegation of abuse to administration immediately, or within two hours. On 02/23/2023, CNA #2 allegedly observed CNA #1 being rough and verbally inappropriate while providing care but did not report the allegation to the Administrator until 02/27/2023 at 1:15 PM, four days later. This failure affected three (Residents #40, #114, and #139) of five sampled residents reviewed for abuse.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure medical records were complete and accurate for one (Resident #253) of 15 residents reviewed for activities of daily living (ADL) documentation.

Inspectors wroteBased on observations, interviews, and review of the facility's policy titled, Procedure for Administration of Pharmaceutical Service, the facility failed to ensure expiration dates were on the label of eleven medications on four of the five medication carts in the facility on [DATE] and [DATE]. This deficient practice affected four of the five medication carts observed. Findings Include: A review of the facility's policy titled, Procedure for Administration of Pharmaceutical Service, with a review date of [DATE], revealed, .The label of each patient's individual medications indicates .expiration date . On [DATE] at 3:29 p.m. the Surveyor with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN ), observed a Medication Cart that contained the following: 1. Docusate Sodium 100 mg (milligram) capsules without an expiration date on the container label. 2. [...]

Inspectors wroteBased on observation, interviews and review of the facility's policy titled, INSTILLATION OF EYE DROPS AND APPLICATION OF EYE OINTMENT, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), provided privacy for Resident Identifier (RI) #190 while administering eye drops in the dining area with twelve other residents present on 11/6/2019. The deficient practice affected one of one resident receiving eye drops during medication administration observations.

Inspectors wroteBased on interview, record review and review of a facility policy titled Grievance, the facility failed to ensure that Resident Identifier (RI) #32's grievance, filed on 10/16/19, was resolved in a timely manner and per facility policy. This affected one of one resident on the sample reviewed for filing a grievance. Findings Include: Review of the facility policy titled Grievance, effective June 2009, revealed the following: . 6. The resident . will be informed of the findings of the investigation and the plan to correct the identified problems . within three (3) working days of the filing of the grievance . 7. Social Services will contact the grieving person approximately two (2) weeks after the plan is established to ensure that it is working properly . [...]

Inspectors wroteBased on observation, interview, record review and review of a facility policies titled MDS (Minimum Data Set) 3.0 & Care Plans and Fall Prevention Policy, the facility failed to implement Resident Identifier (RI) #86's care plan approach for non slip strips in the bathroom to prevent falls. This affected 1 of 35 sampled residents for whom care plans reviewed. Findings Include: A facility policy titled MDS 3.0 & Care Plans, with a revised date of 7/24/14, documented .Purpose: to gather definitive information on a resident's strengths and needs in order to develop an individualized care plan . An undated facility policy titled Falls Prevention Policy documented: . based on individual situations . Interventions are noted on the care plan . RI #86 was readmitted to the facility on [DATE] with diagnoses to include Dementia. A review of RI # 86's care plans revealed: . Problem Onset: [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled Falls Prevention Policy, the facility failed to ensure non-skid strips were placed on Resident Identifier (RI) #86's bathroom floor. This affected 1 of 5 sampled residents reviewed for falls. Findings Include: A review of an undated facility policy titled Falls Prevention Policy revealed: .Residents will be assessed upon admission for the risk of falls . If a score of 10 or above is obtained, the following interventions will be put into place, based on individual situations . Interventions are noted on the care plan . RI # 86 was readmitted to the facility on [DATE] with diagnoses to include Dementia. A review of RI #86's Physician Orders List documented .12/5/18 .PLACE NON SLIP STRIPS ON THE BATHROOM FLOOR FOR SAFETY . [...]