The Summit

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented for 2 (Resident #1 & Resident #3) of 3 sampled residents.

Inspectors wroteBased on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices. The facility failed to ensure activities of daily living tasks performed were accurately documented for 1 (Resident #1) of 3 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 1 (#6) of 2 (#6, #102) residents reviewed for environment. The facility failed to ensure Resident #6 had a call light in reach in order to call for assistance. Total sample size: 41 residents.

Inspectors wroteBased on interview and record review the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #100) of 1 residents reviewed for transfer/discharge. The total sample size was 41.

Inspectors wroteBased on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment within 14 days for 1 (Resident #56) of 1 sampled resident investigated for Resident Assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment/Bi-PAP was stored properly for 1 (Resident #7) of 2 residents reviewed for respiratory care. The total sample size was 41 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident as evidenced by having expired medications available for resident use for 2 (Resident #82 and Resident #89) residents. This had the potential to affect 88 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to: Ensure the Director of Nursing services and the infection preventionist attended the Quality Assessment & Assurance (QAA) committee's quarterly meeting; andConduct QAA meetings at least quarterly for the year of 2025. This had the potential to affect 88 residents who resided in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Resident fed by enteral means received the appropriate treatment and services for 1 (#3) of 3 Sampled Residents. The facility failed to ensure the resident's tube feeding was administered per the physician orders.

Inspectors wroteBased on record review and interview, the facility failed to transmit a Discharge MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #34 and Resident #40) of 2 sampled residents with MDS record over 120 days old.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #77) of 2 (Resident #77 and Resident #20) sampled residents investigated for abuse, in a total sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #5) resident of 20 sampled residents. The facility failed to ensure Resident #5's care plan reflected accurate and current data by failing to resolved/discontinue a previous hospice care plan.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to obtain a physician's order for 1 (#6) of 1 resident sampled for respiratory care. The facility failed to ensure a physician's order was obtained for oxygen administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #10) resident of 20 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for Quality of Care.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The front face coverings for air condition/heater units in rooms a, b, c, d, e, and f were properly secured; 2. The walls in rooms, b, c, e, and f did not have peeling sheet rock; 3. The wall mounted molding near the bedside table in room d, did not have a split in the molding with splinters visible. 4. Handrails on Hall A were cleaned and free of debris and dead insects, and chipped paint was repaired; 5. The floor in Room b had been cleaned of dust and dead insects; and 6. Resident #16's enteral feeding pump was free of dried, splattered feeding.

Inspectors wroteBased on interview, observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #13, Resident #27, and Resident #34) sampled residents in a total sample of 30. The facility failed to ensure a person-centered plan of care was: 1. Implemented for 1 resident (Resident #13) reviewed for impaired mobility. The facility failed to ensure a positioning device was provided to a resident to prevent further complications and contractures. 2. Developed and implemented for 1 resident (Resident #27) that addressed Resident #27's left hand contracture. 3. Developed for 1 resident (Resident #34) who required oxygen therapy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #27) of 2 (Resident #13 and Resident #27) residents sampled for positioning and mobility.

Inspectors wroteBased on observation and interview, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Expired/ outdated items were not available for resident consumption 2. Food preparation equipment was clean 3. Cooking and serving utensils were clean and stored under sanitary conditions. The total Facility census was 102 Residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity for 1 (#2) of 3 sampled residents (Resident #1, Resident #2 and Resident #3). The facility failed to ensure Resident #2 had proper footwear and adequate clothing.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a fall mat beside his bed was followed for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 102 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#1) of 3 (Resident #1, Resident #2 and Resident #3) sampled Residents. The facility failed to ensure: 1. Physician's orders were followed for administering Peg-tube feedings for Resident #1; 2. Resident #1's enteral tube feeding container was labeled.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide adequate supervision of a cognitively impaired resident to prevent elopement for 1 (#2) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice resulted in an immediate jeopardy situation on 09/11/2023 at 5:10 p.m., when Resident #2, who resided on the facility's locked unit (Hall X), and had been identified as a wanderer with a history of exit seeking behaviors, was left unsupervised while outside smoking. Resident #2 climbed over a wooden fence in the courtyard area, unnoticed by staff, and was found by S7 CNA in the parking lot of a department store 900 feet from facility at approximately 5:46 p.m. on 09/11/2023. [...]

Inspectors wroteBased on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 Resident (#2) out of 6 sampled residents (#1, #2, #3, #4, #5, and #6). The facility failed to: 1. Ensure LPN/MDS Nurse accurately assessed Resident #2 who was determined to be at risk for elopement. 2. Have an effective system in place to ensure Resident #2 was adquately supervised to prevent elopement. This deficient practice resulted in an immediate jeopardy situation on 09/11/2023 at 5:10 p.m., when Resident #2, who resided on the facility's locked unit (Hall X), and had been identified as a wanderer with a history of exit seeking behaviors, was left unsupervised while outside smoking. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a plan of care for a resident who required supervision due to wandering/risk for elopement, and supervision during smoking for 1 (#2) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all staff are aware to report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, for 1 (Resident #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure staff reported an incident of resident to resident abuse to facility management.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#2) of 6 (#1, #2, #3, #4, #5, & #6) sampled residents. The facility failed to accurately assess Resident #2 for risk for elopement.