Summersville Healthcare Center

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to perform tracheostomy care within accepted standards of care. This deficient practice had the potential to affect one (1) of one (1) residents observed for tracheostomy care. Resident Identifier: #3. Facility Census: 88.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents received pain management in accordance with professional standards of practice, by not recording the pain level for as-needed (PRN) pain medication. This failed practice was found true for (1) one of (1) one residents reviewed for the care area of pain during the Long-Term Care Survey Process. Resident identifier #3. Facility Census: 88. Findings Include:a) Resident #3A record review on 04/28/26 at 2:22 PM, revealed an order for Resident #3 that read as follows:Hydrocodone-Acetaminophen Tablet 7.5-325 Milligrams (MG): Give one tablet via G-Tube every 6 hours as-needed for pain. A review of the Medication Administration Record (MAR) from 04/02/26 to the present showed that the PRN Hydrocodone-Acetaminophen Tablet was administered 43 times to Resident #3. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure storage of medication within accepted standards of practice. A bottle of medication located in the second floor medication storage room had expired. This was a random opportunity for discovery. Resident Identifier: #3. Facility Census: 88.

Inspectors wroteBased on observation and resident interview, the facility failed to provide meals that were palatable and appetizing for residents of the facility. This has the potential to affect more than a limited number of residents. Resident identifiers: #37, #30, #16, #39, #68, #6, #74, #46. Facility census: 88.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure equipment in which they prepared food, was kept clean and sanitary. This has the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census: 88.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to follow a physician's order regarding blood pressure checks in a restricted arm due to a mastectomy for Residents #28 and #24, and to follow physician orders for Resident #88's fall safety devices to assist in prevention of injury for a resident with a diagnosis and history of repeated falls. This was true for three (3) of 32 reviewed during the survey process. Resident Identifier: #28, #24, #88. Facility Census: 88.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete Physician Orders for Scope of Treatment (POST) forms accurately for Residents #14, #72, #30. This was found to be true for 3 of 32 care plans reviewed. Resident Identifiers #14, #72, #30. Facility Census:88 .

Inspectors wroteBased on resident interview, observation, record interview and staff interview, the facility failed to ensure the call light was accessible to Resident #55 and to have sufficient equipment to ensure Resident #25 could get out of bed to attend Resident Council. This was a random opportunity for discovery. Resident identifier: #55, #25 Facility Census 88.

Inspectors wroteBased on record review and resident, family, and staff interview, the facility failed to honor Resident #30's choices by ensuring she was able to leave the facility with family members, by not allowing her to leave, due to the fact she is on oxygen. This was true for one (1) of one (1) residents reviewed for choices during the survey process. Resident identifier: #30. Facility census: 88.

Inspectors wroteBased on record review and staff interview, the facility failed to provide Resident #74 the right to private communication and ensure mail was delivered on Saturdays. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: #74. Facility Census: 88.

Inspectors wroteBased on record review and staff interview, the facility failed to implement a care plan regarding taking blood pressures in a restricted arm for Resident #24 and #28. This was true for two (2) of 32 care plans reviewed during the survey process. Resident Identifiers: #24 and #28. Facility Census: 88. Findings Included: a) Resident #24 On 11/13/24 at 2:12 PM, a record review was completed for Resident #24. The review found under the focus area of ADL (activities of daily living) self care performance deficit, an intervention listed as NO blood pressures or needle sticks to Left arm due to hx (history) of mastectomy. (Typed as written.) A review under the vital sign tab found 10 documented times the blood pressure was taken in the restricted arm in the last three (3) months. The following dates and times were documented: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide an accident and hazard free environment as possible by having medication at bedside without a physician's order. This was a random opportunity for discovery. Resident Identifier: #68. Facility Census: 88. Findings Included: a) Resident #68 On 11/11/24 at 12:10 PM, an interview was held with Resident #68. During the interview, an observation was made of a bottle of artificial tears at bedside. On 11/13/24 at 3:55 PM, an additional observation was made of a bottle of artificial tears at bedside. On 11/13/24 at 4:00 PM, a review of the record found the resident did not have a physician's order for artificial tears as well as may be kept at bedside. On 11/13/24 at 4:03 PM, Nurse Aide (NA) #21 was interview regarding the artificial tears at bedside. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the appropriate party signed Resident #91's Physician Orders for Scope of Treatment (POST) form. True for 1 of 32 reviewed for advance directives. Resident identifier, resident #91.

Inspectors wroteBased on observation and staff interview, the facility failed to properly implement infection control procedures to prevent the spread of infectious diseases. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 88.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for three (3) of seven (7) residents reviewed who did not receive their medications timely. Resident identifiers: #1, #50, #55. Facility census: 89.

Inspectors wroteBased on observation and staff interview the facility failed to ensure foods were at a palatable temperature at the time of service to the residents. This failed practice had the potential to effect more than an isolated number of residents currently residing at the facility. Facility Census: 89. Findings Included: a) An observation of the breakfast meal service on 01/08/24 beginning at 9:00 am found the breakfast trays on the 400 and 500 hallway were just beginning to be served to the residents. When the last resident tray was served at approximately 9:20 am Registered Nurse # 75 removed the test tray from the cart and obtained the temperature of each food item. The temperatures obtained were as follows: 1. French Toast: 129 degrees Fahrenheit (F). 2. Bacon : 121 degrees F. 3. Cream of wheat (a hot cereal): 117.2 degrees F. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure food was prepared and held at a safe temperature to prevent the spread of food borne illnesses. The facility failed to take temperatures of food at the time of preparation and prior to service for foods held on a steam table. Taking the temperature is critical to ensure food is heated to the appropriate temperature and held at temperatures outside of the food danger zone. The food danger zone is greater than 41 degrees F and/or less than 135 degrees F. The facility utilized a Service Line Checklist that indicated the name of the food items and temperatures for all hot and cold food. The checklist indicated the temperature should be taken prior to service and recorded in the boxes below each food item. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement the Activities of Daily Living (ADL) care plan for four (4) randomly selected residents during a complaint survey. Resident #53, #17, #22 and #38's care plan interventions related to transferring was not implemented. Resident Identifiers: #53, #17, #22 and #38. Facility Census: 86. Findings Included: a) Resident #53 A review of Resident #53's care plan in the morning of 09/28/23 found, Resident #53 was to be transferred via a mechanical lift. This intervention was initiated on 08/24/23 and revised on 09/21/23. Review of Resident #53's ADL flow sheet found on 09/25/23 at 2:09 PM a Nurse Aide documented Resident #53 was transferred with extensive assist of two (2) people. [...]

Inspectors wroteBased on record review and staff interview the facility failed to correctly transfer residents from one surface to another based on their clinical assessment and plan of care. Transferring the residents using incorrect techniques and/or an incorrect number of staff puts each resident at risk for an accident occurring. These accidents could result in serious injury to the residents. This was true for four (4) randomly chosen residents to review for the allegation of safety/falls during a complaint survey. Resident Identifiers: #53, #17, #22 and #38. Facility Census: 86. Findings Included: a) Resident #53 A review of Resident #53's care plan on the morning of 09/28/23 found Resident #53 was to be transferred via a mechanical lift. This intervention was initiated on 08/24/23 and revised on 09/21/23. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the pre planned menus were followed and each resident received the correct serving size of each menu item. This failed practice had the potential to effect more than a limited number of residents currently residing at the facility. Facility Census: 86.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to ensure foods were at a palatable temperature at the time of service to the residents. This failed practice had the potential to effect more than an isolated number of residents currently residents at the facility. Facility Census: 86. Findings Included: a) An observation of the lunch meal service on 09/27/23 began at 11:15 AM. The entire meal service was observed. At the conclusion of the service, [NAME] #86 was asked to put two (2) test trays on the last cart which was heading to the 400/500 units. She did as requested and the meal cart left the kitchen at approximately 12:55 PM. When the last tray from this cart was served to the resident, [NAME] #86 was asked to obtain the temperatures of the food on the two (2) test trays. This temperature was obtained at 1:03 PM on 09/27/23 and was as follows: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure they maintained the nurse staff posting for a minimum of 18 months. This failed practice had the potential to affect all residents currently residing in the facility. Facility Census: 86. Findings Included: a) Upon entrance to the facility on the afternoon of 09/26/23 the nursing schedule and the nurse staff posting for the previous two (2) weeks was requested. The facility provided a nursing schedule with a date range of 09/11/23 to 09/24/23. The facility also provided a nurse staff posting for each of the days from 09/11/23 through 09/24/23. A comparative review of the nurse staff postings with the hours per patient per day report indicated the number of actual staff worked was not the same as nurse staff posting on the days from 09/11/23 to 09/24/23. [...]