Summitview Rehab and Health Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignified care in a manner and in an environment that enhanced dignity and quality of life for 4 of 6 residents (Residents 2, 5, 7 and 28) reviewed for dignity. This failure placed residents at risk for unmet needs and a poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Power of Attorney (POA), was fully informed of the admission agreement to include payment for services and co-payment requirements for 1 of 3 residents (Resident 43) reviewed for admission to the facility. This failure placed the resident/POA at risk for the inability to make informed decisions regarding the resident's health care, alternative treatments and the right to refuse care/services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a process to determine if a potential nursing home resident had a serious mental illness [SMI] or intellectual disability needs which required further assessment/treatment) had the required Level 2 PASARR referral sent when a resident had a positive Level 1 PASARR and was in the facility more than 30 days for 1 of 7 residents (Resident 10) reviewed for PASARR. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement documentation/monitoring of depression symptoms per the comprehensive resident centered care plan and honor resident preferences with nighttime routines for 1 of 6 residents (Resident 38) reviewed for care plan implementation. This failure placed residents at risk for unidentified mental health symptoms and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the nature/terms of entering into a binding arbitration agreement (an alternative means of settling disputes through a third party arbitrator, instead of traditional court/judicial systems) were explained to residents in a form and manner in which they could understand for 2 of 5 residents (Resident 11 and 5) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding concerning the legal contract that had been signed/entered into and being fully informed regarding their choice in the event of a dispute with the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of infections were consistently implemented in the areas of hand hygiene (HH) for 1 of 2 dining rooms (DR 1 and Transmission Based Precautions ([TBP] specialized infection control measures used in health care settings alongside basic standard precautions) for 1 of 2 residents (Resident 12) reviewed for infection control practices. This failure placed the residents at risk for transmission of communicable diseases, and illness.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls with injury, was provided adequate supervision to prevent accident hazards. Resident 1 experienced harm when they were left alone on the toilet and found on the bathroom floor after an unknown amount of time. The fall resulted in a forehead hematoma (a pooling of blood in the surrounding tissues after an injury to the blood vessels) with bleeding, and transfer to the hospital where they were diagnosed with a brain bleed. Failure to identify residents that need supervision while on the toilet put residents at risk for injuries and diminished quality of health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at the proper temperatures, appetizing and palatable to taste for 4 of 7 residents (Resident 20, 25, 42, and 43) reviewed for nutrition. This failure placed residents at risk for foodborne illnesses, a decreased nutritional intake, and potential for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained by not performing hand hygiene and glove changes between dirty and clean tasks for 3 of 4 staff (Staff R, T and Q) reviewed during resident cares and dining. This failed practice placed residents at an increased risk for exposure to cross contamination (harmful spread of infections) and the development of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's right to choose important aspects of their life including frequency and type of bathing preferences for 2 of 3 residents (Residents19 and 29) reviewed for choices. This failure to honor resident choices placed the residents at risk for impaired hygiene and feelings of embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the minimum requirements of resident specific goals, physician orders, dietary orders, treatment plans and social service needs for 3 of 5 residents (Residents 29, 208, and 258) reviewed for baseline care plan. This failure placed residents at risk of not receiving necessary care and services, and a continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care plans were developed with appropriate interventions for 2 of 2 residents (Resident 18 and 208) reviewed for care planning. This failure to develop care plans with appropriate interventions placed the residents at risk for inadequate or unsafe care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of bathing, nail care, and oral care for 3 of 10 dependent residents (Residents 26, 41 and 15) reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene, body odor, dental caries (cavities or tooth decay), decreased self-worth and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 of 3 sampled residents (Residents 41and 18) reviewed for positioning and range of motion received services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of assistive devices. This failure increased the resident's risk of being unable to maintain their current level of functioning, increased risk of pain and breaks in skin integrity related to a contracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor food preferences for 2 of 4 residents (Resident 29 and 32) reviewed for dietary preferences. This failure placed the residents at risk for dissatisfaction with their dining experience and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded, for 1 of 2 nutritional refrigerators (recreational room refrigerator), reviewed for food safety. This failure placed residents at risk of consuming contaminated, expired foods and obtaining a food-borne (a disease transmitted to people by food) illness.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent injuries or falls, during resident transfers (helping residents move safely from one place to another) for 2 of 5 residents (Resident 1 and Resident 4) reviewed for falls or injuries acquired during transfers by staff. Resident 1 experienced harm when the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in pain and ankle fractures and put residents that require transfer assistance at risk for injury.

Inspectors wroteBased on interview and record review the facility failed to notify the local health jurisdiction (LHJ) and the State of a communicable disease outbreak within required time frames for 20 of 20 residents (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19, and 20) reviewed for symptoms of a highly contagious gastro-intestinal (GI) illness starting on 11/18/2024. Additionally, 19 staff reported symptoms with the last symptom onset on 12/09/2024. These failures placed residents at risk for a diminished quality of life, unmet care needs and placed residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice to prevent facility acquired pressure injury (PI) and worsening of PIs for 2 of 3 residents (Residents 49, and 18) reviewed for PIs. Resident 49 experienced harm when they developed a stage 4 medical device-related PI (MDRPI) to their right lower leg from an immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) that became infected and resulted in extreme pain. Resident 18 experienced harm when they developed a right buttock PI that worsened, became infected, and required antibiotic treatment. These failures placed residents at risk for medical complications, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) including incorporating ADs into the care planning process for 1 of 5 residents (Resident 10) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 3 residents (Residents 27 and 13) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for 2 of 3 residents (Resident 27 and 13), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the continued exposure to abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize a significant change in status assessment needed to be completed for 1 of 2 residents (Resident 18) reviewed for comprehensive assessments who experienced a decline in skin integrity, weight loss, and swallowing and eating abilities. Failure to complete significant change of status care assessment placed the resident at risk for not receiving the care and services they required.

Inspectors wrote<Resident 36> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including delusional disorder (a type of mental health condition in which a person cannot tell what is real from what is imagined) and developmental disorder (impairments in physical, cognitive, language, or behavioral development). The comprehensive assessment dated [DATE] showed that resident had an impaired cognition and required extensive assist of one staff member for activities of daily living. Review of a Physicians visit note dated 07/25/2023, showed a diagnosis of Paranoid Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves. It causes a person to fear that others are watching them or trying to harm them) was added for Resident 36. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 1 of 5 newly admitted residents (Residents 49) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion (ROM) received the necessary services to maintain their level of positioning in their tilt in space wheelchair (a wheelchair that can be tilted from the head rest to the seat of the wheelchair without changing the angle of the whole wheelchair) without further decline for 1 of 1 resident (Resident 20), reviewed for limited ROM and wheelchair positioning. This failure placed the resident at risk for increased pain, skin breakdown, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide prompt routine dental services for 1 of 3 resident (Resident 29) reviewed for dental services. The failure placed the resident at an increased risk for dental care complications and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine dental services were provided for 1 of 2 residents (Resident 20) reviewed for dental services. The failure to act on a routine dental referral for examinations, x-rays, and cleaning, resulted in a delay in treatment and placed the resident at risk for dental pain, difficulty chewing, and unmet dental needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions for, 1) hand hygiene and glove change for 3 of 10 staff (Staff BB, CC, and DD) reviewed during resident cares and wound treatment, 2) central venous catheter (central line, a tube often place through the skin in a large vein in the neck, chest or groin so that the tip of the tube sits near the heart in order to give medication/fluids or to collect blood and can remain in place for a longer period of time than normal venous catheters) sterile (free from bacteria ,totally clean) dressing change for 1 of 1 resident (Resident 8) reviewed for infection control practices, and 3) use of Personal Protective Equipment (PPE) in an enhanced barrier precautions (EBP, indicated with high contact resident care activities with an infection, a long term [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, and sanitary environment for 3 of 10 resident rooms (rooms [ROOM NUMBER]) that had large gouges (indentation or groove made in a surface to cause holes or damage)/peeling paint from the walls, 1 of 2 soiled utility rooms (600 hallway), 1 of 2 clean utility rooms (600 hallway), and 1 of 1 laundry room (LR1), reviewed for a safe and sanitary environment. This failure placed staff and residents at an increased risk for infections related to non-cleanable surfaces and not feeling safe/secure with their environment.