Summit Health and Rehab Center

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician/provider of an assessed pressure injury requiring care orders for one of five residents in the survey sample (Resident #1).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to thoroughly assess and implement timely interventions for care of a pressure ulcer for one of five residents in the survey sample (Resident #1).

Inspectors wrote2. For Resident #84, facility staff failed to verify the resident's name on a pharmacy supply card prior to preparation for the adminisration of medications during a medication pass observation on The Gardens unit. The medication torsemide 40 mg (milligrams) was pulled for Resident #84 from a pharmacy supply card labeled for Resident #159. On 4/30/25 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #7) administering medications to Resident #84 (R84). Among the medications prepared for R84 were two tablets of torsemide 20 mg. LPN #7 accessed the torsemide tablets from a pharmacy supply card labeled for Resident #159 (R159). The medication pass was paused prior to the administration to R84 and LPN #7 was questioned about the torsemide obtained from R159's supply card. [...]

Inspectors wroteBased on observations, interviews, clinical record review, and facility policy review, 1.) the facility failed to implement enhanced barrier precautions (EBP) during high contact resident care for two residents (Resident (R) 86 and R63) ; 2.) the facility failed to implement contact precautions measure in posting appropriate signage and ensuring appropriate PPE was readily available in the care of one resident (R7); 3.) the facility staff failed to perform the standard precautions of appropriate hand hygiene with incontinent care and with handling clean linen to prevent risk of cross contamination for one of one resident (R36); [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to honor a preference for twice weekly showers for one of thirty residents in the survey sample (Resident #112).

Inspectors wrote2. For Resident #110 (R110), the facility failed to notify the physician and responsible party of the dislodgement of a enteral feeding tube. Review of the Face Sheet found in R110's EMR under the Profile tab revealed R110 was admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness of unspecified duration, gastrostomy status, dysphagia, and protein-calorie malnutrition. Review of R110's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/24 revealed the resident had short- and long-term memory problems and the resident's cognitive decision making was severely impaired. Further review revealed the resident was dependent on staff for eating and required a feeding tube. [...]

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for reporting an injury of unknown origin for one of thirty residents in the survey sample (Resident #111).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to immediately report to the state agency and adult protective services (APS), an injury of unknown origin suspicious of abuse for one of thirty residents in the survey sample (Resident #111).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide the resident and/or resident representative with a baseline care plan summary for one of thirty residents in the survey sample (Resident #37).

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of thirty residents in the survey sample (Resident #91).

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide incontinence care for in a timely manner for two of three residents (Resident (R) 36 and R41) reviewed for activities of daily living (ADLs) out of a total sample of 30. Failure to provide timely incontinence care places residents at increased risk of urinary tract infections and skin breakdown.

Inspectors wroteBased on interview, record review, and job description review, the facility failed to have a certified Activity Director to direct the provision of activities for 114 of 114 residents, as required.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a wound dressing was intact for one of thirty residents in the survey sample, (Residents #19). Resident #19's (R19) did not have a wound dressing in place. The Findings Include: Diagnoses for R19 included non-pressure chronic ulcer to left calf, adult failure to thrive, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/19/25. R19 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. On 4/29/25 at 12:55 p.m., R19 was interviewed and was asked about having any wounds. R19 verbalized that he had a wound on the left calf that has been there before being admitted and the nurses are taking care of it. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to implement interventions to aid in the prevention of pressure ulcers for one of three residents (Resident (R) 36) reviewed for pressure ulcers out of a total sample of 30. Failure to implement interventions placed R36 at increased risk of developing pressure ulcers.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to ensure the environment was free of accident hazards for one resident (Resident #88) and failed to provide adequate supervision to prevent accidents for two residents (Resident #36 and Resident #69), in a sample of thirty residents.

Inspectors wroteBased on staff interview, record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for 7 Residents (Resident #1, #2, #3, #6, #7, #9, and #10) in a survey sample of 11 Residents. For Resident #1, #2, #3, #6, #7, #9, and #10, the facility staff failed to administer medications in accordance with physician orders and failed to notify the physician that the ordered medications were not administered.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pharmaceutical services to meet the needs of 4 Residents (Resident #1, #2, #4, and #6) in a survey sample of 11 residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from significant medication errors, affecting 5 residents (Resident #1, #5, #6, #9, and #11), in a survey sample of 11.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the POA (power of attorney) of a change in condition for one resident (Resident #11) in a survey sample of 11 Residents.

Inspectors wroteBased on staff interview, resident interviews, and facility document review, the facility staff failed to offer alternate menu entrée items that were prepared in advance and compatible to other menu items. No meal alternatives menu entrée items were listed on the main menus posted on each unit, or on the copy provided to the residents. The census was 79 residents.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control protocols for one of twenty-one residents in the survey sample, Resident #75; and failed to implement facility protocols for Legionella prevention.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician of medications not available for administration for three of 21 residents in the survey sample, Resident #230, Resident #59 and Resident #15.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 3 of 21 residents in the survey sample, Resident #28, Resident #13, and Resident #15. Resident #28's CCP did not include a focus area with goals and interventions for the use of antidepressants. Resident #13's CCP did not include a focus area with goals and interventions for nutrition. Resident #15's CCP did not include a focus area with goals and interventions for having an impacted ear related to wax build-up.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of twenty-one residents in the survey sample, Resident #15, #23, and #230. A nurse administered the medication Depakote to Resident #15 in error. There was no report or investigation of the error by nursing administration. Resident #23 was administered a deep IM (intramuscular) injection of an antibiotic in the deltoid muscle which was against the manufacturer's recommendation. The facility failed to accurately transcribe a physician's order resulting in Resident #230 missing an IV (intravenous) antibiotic (Vancomycin) for four days.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure six of 21 residents in the survey sample were administered medications as ordered by the physician, Resident #230, #59, #15, #46, and #14; and failed to ensure glucometer calibration monitoring was completed on three of 4 nursing units, The Gardens, [NAME] Square, and The Peaks. 1. Resident #230 was not administered IV (intravenous) Vancomycin, oral Vancomycin, or Aricept as ordered by the physician. 2. Resident #59 was not administered a sodium chloride supplement or medications for a bowel regimen as ordered by the physician. 3. [...]

Inspectors wrote3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. a) On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. [...]

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure two of 21 residents in the survey sample were free of a significant medication error, Resident #230 and #59. Resident #230 was not administered IV (intravenous) antibiotics for a blood infection for four consecutive days; and Resident #59 was not administered sodium chloride for hyponatremia for 5 days and wasn't administered a bowel regimen, Dulcolax for 9 days.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to evaluate for self administration of medications for one of 21 residents, Resident #8. The Findings Include: Diagnoses for Resident #8 included; Pneumonia, sepsis, chronic kidney disease, and major depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/29/22. Resident #8 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 4/19/22 at 10:56 a.m., while interviewing Resident #8 medications were observed on the bedside table in a dispense cup. Resident #8 verbalized not wanting to take the medications until after breakfast so had asked the nurse to leave them on the table. On 4/19/22 at 11: [...]

Inspectors wroteBased on staff interview, and clinical record review, the facility failed to document a discharge to the hospital in the clinical record for one of 21 residents, Resident #12. The Findings Include: Resident #12 was admitted with diagnosis that included: Dementia, Hypotension, dysphagia, peripheral vascular disease, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 2/25/22. Resident #12 was assessed with a cognitive score of 10 indicating moderately cognitively intact. On 4/19/22 Resident #12's medical record was reviewed. The MDS list indicated Resident #12 had been discharged to the hospital on 3/15/22. Review of the progress notes dated 3/15/22 indicated Resident #12 was found in bed with . [...]

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure admission orders for the immediate care and services of a central line catheter for one of 21 residents in the survey sample, Resident #230.

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure a baseline care plan for a central venous access catheter was completed for one of 21 residents in the survey sample, Resident #230.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide pain management for 1 of 21 residents in the survey sample, Resident #14. Resident #14 was not administered scheduled Lidocaine 4% patches for 4 consecutive days.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a dementia care plan for 1 of 21 in the survey sample, Resident #13. Resident #13 who was diagnosed with dementia without behavioral disturbance did not have a dementia specific care plan including person centered interventions.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure medications and biologicals were dated when opened on two of 4 units, Town Square and The Gardens. On the Peaks unit, facility staff failed to ensure an expired medication was not available for administration. A bottle of oral vancomycin (an antibiotic) was dated as do not use beyond 4/18/22 was still in the medication refrigerator.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to have an physician's order for a therapeutic diet for Resident #13. Resident #13's clinical record did not document a nutrition/diet order upon readmission from the hospital.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for 1 of 21 residents in the survey sample, Resident #35. Records of weekly hospice visits for Resident #35 were not provided to the facility as required in the hospice services agreement.

Inspectors wroteBased on clinical record review, review of Medicare Beneficiary Notices, and staff interview, the facility staff failed to provide the residents with a Medicare notice of non-coverage for three (3) of three (3) residents, Residents # 18, 128, and 130. The residents were not provided notices of Medicare Part A non-coverage prior to their last day of Part A service.

Inspectors wroteBased on clinical record review and staff interview, facility staff failed to obtain physician orders for the immediate care of a wound vac for one of 22 residents, Resident #89.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for two of 21 residents. Resident #89 was admitted to the facility with a wound vac and a port-a-cath, and Resident #85 was admitted with a wound vac. A baseline care plan for the devices was not developed for either resident.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 22 residents in the survey sample. Resident #62 had no plan of care regarding use of a mitten and Resident #85 had no care plan regarding wound vacuum treatment.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one 22 residents, Resident #86. Interventions regarding the use of a PICC (Peripherally Inserted Central Catheter) line and the administration of IV (intravenous) antibiotics were not removed from the care plan when they were discontinued.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately assess, obtain informed consents and attempt alternatives prior to the use of bed rails for two of 22 residents in the survey sample. Residents #11 and #62 had bed rails in use with conflicting safety assessments, no prior attempted alternatives and without informed consent from their responsible parties.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure one of 22 residents was free from unnecessary medication. Resident #62 had a prn (as needed) physician's order for the anti-anxiety medication Lorazepam in place for over 14 days without a documented rationale and specified duration.