10 Reports
Inspection Report — Apr 22, 2025
Annual Inspection
Date: Apr 22, 2025
Visit Reason
Annual inspection survey of The Summit nursing home to assess compliance with federal and state regulations related to quality of care, skin integrity, pressure ulcer prevention, and fall prevention.
Findings
The facility was found deficient in ensuring proper wound care treatments, skin assessments, and documentation for sampled residents. Deficiencies were also noted in fall investigations and prevention measures, as well as in maintaining a safe environment free of accident hazards.
Deficiencies (3)
F684 Quality of care: The facility failed to ensure wound care treatments and skin assessments were completed and documented for sampled residents, including Resident #3 with chronic wounds and Resident #2 with pressure ulcers. Documentation gaps and inconsistent treatment were noted.
F686 Skin integrity: The facility failed to ensure weekly wound tracking, measuring, and skin assessments were completed and documented for sampled residents with pressure ulcers, including Resident #1 and Resident #2. Policies for pressure ulcer treatment were not fully followed.
F689 Free of accident hazards: The facility failed to ensure complete and thorough fall investigations for three sampled residents, including lack of root cause analysis and incomplete documentation. Fall prevention policies and procedures were not fully implemented.
Report Facts
Deficiency count: 3
Inspection Report — Aug 21, 2024
Complaint Investigation
Date: Aug 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged financial exploitation of a resident by a Certified Nursing Assistant (CNA A).
Complaint Details
The complaint investigation substantiated financial exploitation of Resident #1 by CNA A, who was terminated for unprofessional behavior. The resident was deaf and cognitively impaired, and CNA A exploited the resident's inability to communicate effectively to access and withdraw funds. Law enforcement and the ombudsman were involved, and criminal charges were pending against CNA A.
Findings
The facility failed to provide protective oversight for a resident who was exploited financially by a CNA who accessed the resident's bank accounts without proper authorization. The investigation revealed multiple unauthorized withdrawals totaling over $24,000 and inadequate protective policies and oversight.
Deficiencies (4)
F602: The facility failed to protect a resident from financial exploitation by a CNA who accessed the resident's bank accounts without proper authorization and withdrew $24,952.83. The facility did not provide adequate protective oversight or prevent abuse, neglect, or misappropriation of resident property.
A4074: The facility failed to ensure twenty-four-hour protective oversight and supervision for residents on voluntary leave, contributing to the exploitation incident. Refer to F602 for details.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, including misappropriation of resident property. Refer to F602 for details.
A8030: The facility failed to ensure dignity and privacy for residents during care and treatment. Refer to F602 for details.
Report Facts
Unauthorized withdrawal amount: 24952.83
Resident checking account balances: 1522.66
Resident money market account balances: 21309.24
Resident checking account balances: 297.17
Resident money market account balances: 9828.87
Resident rent balance due: 4855
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in financial exploitation finding and terminated for unprofessional behavior |
| Nasonika Evans | Administrator | Signed the inspection report and plan of correction |
Inspection Report — May 15, 2023
Routine
Date: May 15, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report — Mar 17, 2022
Plan of Correction
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to investigate and address deficiencies related to resident rights and dignity following an incident involving a discharged resident and staff behavior during a meal service.
Findings
The facility failed to ensure that a discharged resident was treated with dignity and respect during a breakfast meal, involving yelling and inappropriate language by a Dietary Cook. The facility's policies on resident rights and staff conduct were reviewed and found insufficiently enforced.
Deficiencies (2)
F550 Resident Rights/Exercise of Rights. The facility failed to ensure one discharged resident was treated with dignity and respect during a breakfast meal when a Dietary Cook cursed and yelled at the resident.
A8030 Dignity/Privacy. Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality. This regulation was not met as evidenced by the F550 deficiency.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook (DC) A | Named in the finding for yelling and cursing at a resident during a meal | |
| Dietary Manager (DM) | Interviewed regarding the incident between Resident #1 and DC A | |
| Administrator | Interviewed about staff expectations and incident reporting |
Inspection Report — Feb 4, 2022
Routine
Date: Feb 4, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report — Sep 16, 2021
Complaint Investigation
Date: Sep 16, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow transfer and discharge protocols for one sampled resident who received an emergency discharge.
Complaint Details
The complaint investigation was substantiated. The facility failed to follow proper transfer and discharge protocols for one resident who was discharged to a homeless shelter in an emergency situation. Documentation, notification, and nursing assessments were inadequate, and the resident's safety was endangered due to aggressive behavior.
Findings
The facility failed to follow transfer/discharge protocols for one resident discharged to a local homeless shelter without proper documentation, notification, or assessment. The resident's safety was endangered due to aggressive behavior and inadequate staff interventions.
Deficiencies (5)
F622 Transfer and Discharge Requirements: The facility failed to follow transfer/discharge protocols for one resident discharged to a homeless shelter without proper documentation, notification to the physician, or nursing assessment. The resident exhibited aggressive behavior and the facility did not adequately intervene or document the discharge process.
F626 Permitting Residents to Return to Facility: The facility failed to allow one resident to return after an emergency discharge and appeal, violating readmission requirements. The resident's rights and discharge procedures were not properly followed.
A8015 19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: The facility did not provide required 30-day notice to the resident's representative and attending physician prior to transfer/discharge, violating regulatory requirements.
A8016 19 CSR 30-88.010(16) Reasons to Transfer/Discharge: The facility failed to meet regulatory requirements for transfer/discharge reasons, referencing deficiencies F622 and F626.
A8018 19 CSR 30-88.010(18) Emergency Discharges: The facility failed to provide timely written notice of emergency discharge to the resident and legally authorized representative, violating regulatory requirements.
Report Facts
Number of sampled residents: 3
Deficiency count: 5
Inspection Report — Aug 11, 2021
Life Safety
Date: Aug 11, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related smoking regulations at the facility.
Findings
The facility failed to prevent residents from smoking in non-designated areas, lacked proper smoking signage, and did not ensure self-closing devices for cigarette butt disposal were present. These deficiencies potentially affected all residents, visitors, and staff.
Deficiencies (2)
K741 Smoking Regulations: The facility failed to prevent residents from smoking in non-designated areas, lacked proper smoking signage, and did not ensure self-closing devices for cigarette butt disposal were present in all smoking areas.
A2003 No Fire Hazard: The building did not present a fire hazard as evidenced by compliance with K741.
Report Facts
Number of active smokers: 19
Inspection Report — Jul 2, 2020
Complaint Investigation
Date: Jul 2, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate Cardiopulmonary Resuscitation (CPR) to a resident requiring emergency care.
Complaint Details
The complaint investigation found the violation to be at an imminent danger Class I level based on observation, interview, and record review. The facility implemented corrective actions during the onsite visit, lowering the severity to Class II at exit.
Findings
The facility failed to ensure adequate CPR was provided by trained staff to a resident with full code status who suffered cardiac arrest. The Licensed Practical Nurse (LPN) initiated CPR but discontinued it prematurely, and no CPR-certified staff was present until EMS arrival.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR): Personnel failed to provide adequate CPR to a resident requiring emergency care, as evidenced by a Licensed Practical Nurse discontinuing CPR prematurely and lack of CPR-certified staff until EMS arrival.
A4074 Nursing Care per Resident Condition: Each resident did not receive personal attention and nursing care consistent with current acceptable nursing practice, related to the CPR deficiency.
Report Facts
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in the CPR deficiency for initiating and discontinuing CPR on the resident |
| EMS A | Emergency Medical Services staff | Responded to the emergency and performed CPR after arrival |
Inspection Report — May 26, 2020
Abbreviated Survey
Date: May 26, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with related CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparation and infection control.
Inspection Report — Mar 19, 2020
Complaint Investigation
Date: Mar 19, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident on 03/10/2020.
Complaint Details
The complaint investigation was substantiated. The resident eloped from the facility on 03/10/2020 and was found outside at a bar. The facility failed to monitor and supervise the resident adequately and did not notify the physician or follow elopement policies.
Findings
The facility failed to provide adequate supervision and assistance to prevent elopement for one resident, resulting in the resident leaving the facility unsupervised. The facility did not follow their own policies for resident assessment, monitoring, and incident documentation.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide supervision to prevent elopement for one resident, did not complete an elopement risk assessment on admission, and failed to follow the resident care plan and incident reporting policies.
A4073 Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave, resulting in an imminent danger class I level violation.
Report Facts
Dates of interviews and observations: Multiple dates between 03/10/2020 and 03/19/2020 related to interviews and observations
7 CMS Surveys
Inspection Report — Dec 8, 2025
Date: Dec 8, 2025
Visit Reason
The inspection was conducted to assess the facility's pest control program, specifically regarding the presence and management of bedbugs in resident rooms.
Findings
The facility failed to maintain an effective pest control program for 6 of 15 sampled residents, with live bedbugs observed in their rooms. The facility had a bedbug policy and was using heat treatment and spraying protocols, but infestations persisted, and some residents resisted treatment.
Deficiencies (1)
Failure to maintain an effective pest control program to prevent/deal with mice, insects, or other pests, specifically bedbugs.
Report Facts
Residents affected: 6
Sampled residents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Reported bedbugs found in Resident #14's bra, curtains, bed and floor |
| Certified Nursing Assistant A | CNA | Described staff efforts to manage rooms with bedbugs and resident cooperation |
| Certified Nursing Assistant B | CNA | Reported checking resident rooms for bedbugs and handling infested clothing |
| Maintenance Director | Described pest control efforts and heat treatment process | |
| Corporate Maintenance Director | Oversaw bedbug treatment program and coordination with facility maintenance | |
| Director of Nursing | DON | Discussed bedbug presence and treatment protocols |
| Corporate Director of Operations | Described internal bedbug extermination program and heat treatment machines | |
| Exterminator A | Provided information on pest control treatments and facility practices | |
| Administrator | Discussed history of bedbug issues and treatment strategies at the facility | |
| Social Worker | Reported on Resident #7's situation and challenges with room treatment |
Inspection Report — Apr 22, 2025
Routine
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to assess compliance with wound care treatments, skin assessments, pressure ulcer care, and fall prevention protocols for sampled residents.
Findings
The facility failed to ensure wound care treatments and skin assessments were completed and documented for sampled residents, including weekly wound tracking and measuring. Fall investigations were incomplete and lacked thorough root-cause analysis for several residents. Documentation and care plans were often missing or incomplete.
Deficiencies (3)
Failed to ensure wound care treatments and skin assessments were completed and documented for Resident #3.
Failed to ensure wound care treatments were completed and documented including weekly wound tracking and measuring for Resident #2 and weekly skin assessments for Resident #1.
Failed to ensure fall investigations were complete and thorough to include root-cause analysis for Residents #1, #4, and #5.
Report Facts
Missed wound treatment documentation: 7
Missed wound treatment documentation: 8
Missed wound treatment documentation: 7
Missed wound treatment documentation: 10
Missed wound treatment documentation: 15
Missed wound treatment documentation: 12
Missed wound treatment documentation: 1
Missed wound treatment documentation: 9
Missed wound treatment documentation: 7
Missed wound treatment documentation: 2
Missed wound treatment documentation: 17
Missed wound treatment documentation: 9
Falls: 2
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Interviewed regarding wound care treatments and skin assessments for Residents #2 and #3 |
| Certified Nursing Assistant A | CNA | Interviewed regarding skin checks and wound care for Residents #2 and #3 |
| Licensed Practical Nurse B | LPN | Interviewed regarding wound treatment documentation and fall investigations |
| Director of Nursing | DON | Interviewed regarding responsibility for wound care, skin assessments, and fall investigations |
Inspection Report — Aug 21, 2024
Complaint Investigation
Date: Aug 21, 2024
Visit Reason
The investigation was initiated due to allegations of financial exploitation of a hearing-impaired resident by a Certified Nursing Assistant (CNA A) who took the resident out of the facility to a bank and accessed the resident's accounts without appropriate interpreter presence.
Complaint Details
The complaint was substantiated. CNA A exploited a hearing-impaired resident by accessing and withdrawing funds from the resident's bank accounts without informed consent or interpreter presence. Law enforcement is pursuing criminal charges against CNA A.
Findings
The facility failed to provide protective oversight, allowing CNA A to exploit the resident by withdrawing $24,952.83 from the resident's accounts. The resident was cognitively impaired and hearing impaired without speech, relying on alternative communication methods. CNA A was terminated prior to the exploitation incident. The bank and law enforcement were involved, and the resident was distressed by the exploitation.
Deficiencies (1)
Failed to protect resident from wrongful use of belongings or money resulting in financial exploitation by a CNA.
Report Facts
Amount withdrawn: 24952.83
Last rent payment: 3822
Balance due: 4855
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Employee who exploited the resident financially and was terminated for unprofessional behavior. |
| Social Services Designee | Social Services Designee | Interviewed regarding resident's financial exploitation and facility response. |
| Administrator | Facility Administrator | Provided information about CNA A's termination and resident complaints. |
| Bank Representative | Bank Representative | Provided details on account activity, lack of interpreter policy, and bank's response. |
| Law Enforcement Officer | Law Enforcement Officer | Reported criminal investigation and charges against CNA A. |
| Ombudsman | Ombudsman | Interviewed about resident's emotional state and exploitation. |
Inspection Report — Sep 14, 2023
Routine
Date: Sep 14, 2023
Visit Reason
Routine inspection of a nursing home facility to assess compliance with regulatory requirements including resident care, safety, staffing, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, incomplete assessments and care planning for restraints and colostomy care, inadequate bed hold notification and documentation, inaccurate and untimely Minimum Data Set (MDS) assessments, failure to maintain CPR certification for all staff, incomplete smoking safety assessments and monitoring, inadequate behavioral health management, failure to monitor antibiotic use properly, inaccurate Payroll Based Journal (PBJ) staffing submissions, inadequate food service staffing and food safety practices, failure to maintain proper infection control program including waterborne illness prevention, and failure to post accurate nurse staffing information.
Deficiencies (18)
Failed to ensure resident privacy by not maintaining operable privacy curtains for a sampled resident.
Failed to assess and obtain physician's order for physical restraint devices including seatbelt use for a sampled resident.
Failed to ensure bed hold forms were completed and documented for residents transferred to hospital.
Failed to complete accurate and timely Minimum Data Set (MDS) assessments for sampled residents.
Failed to develop complete care plans within 7 days of comprehensive assessment and update care plans to reflect current resident status.
Failed to maintain current CPR certification for all staff and failed to have a process to identify CPR certified staff.
Failed to complete smoking safety assessments, monitor safe storage of smoking materials, and reassess resident smoking ability after incidents.
Failed to obtain physician's order for colostomy care and monitoring, failed to assess resident's ability for self-care, and failed to document stoma site assessments.
Failed to identify, assess, and treat a resident with gradual weight loss and dental issues, and failed to develop and implement a care plan with related interventions.
Failed to transcribe physician's order for dialysis AV shunt monitoring to Treatment Administration Record (TAR) and failed to document monitoring as ordered.
Failed to post nurse staffing information daily including resident census, current date, and actual hours worked in a manner accessible to residents and visitors.
Failed to maintain food safety and sanitation including dishwasher cleanliness, proper food storage and labeling, and cleanliness of kitchen equipment and floors.
Failed to ensure resident preference for non-lactose milk was met for a period of 17 days.
Failed to ensure facility had contracts with each resident's dialysis site.
Failed to provide appropriate behavioral health care and management including behavioral monitoring and care plan updates for a resident with behavioral issues.
Failed to provide or get specialized rehabilitative services in a timely manner as ordered by physician.
Failed to electronically submit accurate Payroll Based Journal (PBJ) staffing data for three of the last four quarters.
Failed to have a waterborne illness prevention program including annual backflow prevention test, facility specific risk assessment, water system diagram, testing protocols, response protocols, water management team, and staff training on Legionnaires' disease.
Report Facts
Weight loss percentage: 6.4
Weight loss percentage: 8
PBJ Quarter Three 2022: 0
PBJ Quarter Four 2022: 0
PBJ Quarter Two 2023: 0
AV shunt monitoring opportunities: 93
AV shunt daily monitoring opportunities: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in findings related to resident privacy curtain, seatbelt restraint, behavioral incident, and behavioral monitoring |
| CNA B | Certified Nursing Assistant | Named in findings related to resident privacy curtain, smoking safety, colostomy care, and behavioral monitoring |
| LPN B | Licensed Practical Nurse | Named in findings related to resident privacy curtain, behavioral incident, and behavioral monitoring |
| CMT A | Certified Medication Technician | Named in findings related to resident privacy curtain, colostomy care, dialysis monitoring, behavioral incident, and weight monitoring |
| RN B | Registered Nurse | Named in findings related to dialysis AV shunt monitoring and behavioral monitoring |
| LPN C | Licensed Practical Nurse | Named in findings related to dietary staffing and resident food preferences |
| Dietary Manager | Dietary Manager | Named in findings related to dietary staffing, food safety, and resident food preferences |
| Administrator in Training | Administrator in Training | Named in findings related to CPR certification, nurse staffing posting, dietary staffing, and behavioral incident |
| Director of Nursing | Director of Nursing | Named in findings related to resident privacy, restraint assessment, bed hold forms, MDS assessments, colostomy care, weight monitoring, dialysis monitoring, nurse staffing posting, behavioral health, and antibiotic stewardship |
| Social Services Designee | Social Services Designee | Named in findings related to bed hold forms, MDS assessments, care plan meetings, smoking safety, and behavioral health |
| Certified Medication Technician B | Certified Medication Technician | Named in behavioral incident involving resident and nurse |
| Dentist A | Dentist | Named in findings related to dental care for resident |
| Registered Dietitian | Registered Dietitian | Named in findings related to dietary services and resident food preferences |
| Corporate Maintenance Person | Corporate Maintenance Person | Named in findings related to dumpster lid and waterborne illness prevention |
| Corporate Maintenance Director | Corporate Maintenance Director | Named in findings related to backflow prevention test scheduling |
| Administrator | Administrator | Named in findings related to dialysis contracts and waterborne illness prevention |
| Licensed Practical Nurse D | Licensed Practical Nurse | Named in findings related to CPR certification |
| Certified Nursing Assistant C | Certified Nursing Assistant | Named in findings related to CPR certification |
Inspection Report — May 15, 2023
Annual Inspection
Date: May 15, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Jul 22, 2022
Routine
Date: Jul 22, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure timely and accurate Minimum Data Set (MDS) assessments, incomplete care plans addressing resident needs such as anticoagulation, pain, oxygen, and behavioral monitoring, inadequate infection control surveillance and tuberculosis screening, improper oxygen therapy management, unsafe smoking practices without proper assessments or care plans, incomplete fall investigations and interventions, pest control issues including bedbugs and flies, and failure to ensure proper food storage and menu substitutions were reviewed by dietitians.
Deficiencies (18)
Failure to ensure residents received mail on mail delivery days and mail privacy was not maintained.
Failure to maintain resident rooms and common areas free from dust, debris, and damage.
Failure to establish and implement a grievance policy ensuring prompt resolution and protection from retaliation.
Failure to complete Nurse Aide Registry checks for employee background screening.
Failure to notify residents and Ombudsman in writing of transfers or discharges including appeal rights.
Failure to provide written notification of bed hold policy to residents or responsible parties upon hospital transfer.
Failure to complete and submit comprehensive Minimum Data Set (MDS) assessments timely.
Failure to complete a Significant Change MDS for a resident starting dialysis.
Failure to complete and submit quarterly MDS assessments timely.
Failure to ensure accuracy of comprehensive assessments for residents.
Failure to develop and implement complete, accurate, and individualized care plans addressing specific resident needs including anticoagulation, pain, oxygen, and behavioral monitoring.
Failure to provide activities to meet all residents' needs including assessment of preferences and ongoing programming.
Failure to provide appropriate treatment and care including skin assessments and wound monitoring.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents including fall investigations, reassessments, and care planning; failure to assess and monitor residents' ability to smoke safely and provide smoking care plans.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards including cleanliness and maintenance of kitchen equipment and storage areas.
Failure to have a policy regarding use and storage of foods brought to residents by family and visitors including labeling and dating of food containers.
Failure to dispose of garbage and refuse properly including uncovered trash containers in kitchen and dining room.
Failure to provide and implement an infection prevention and control program including incomplete surveillance logs, lack of tuberculosis screening documentation for employees, and inadequate tracking and trending of infections.
Report Facts
Residents affected: 51
Employees missing Nurse Aide Registry check: 4
Months of incomplete infection control surveillance: 7
Residents observed smoking without supervision: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding multiple deficiencies including MDS submissions, care plans, infection control, and fall investigations | |
| Social Services Director | Interviewed regarding grievance policy, smoking assessments, and care plans | |
| Licensed Practical Nurse | Interviewed regarding employee background screening, care plans, oxygen therapy, wound care, and fall investigations | |
| Certified Nursing Assistant | Interviewed regarding care plans, smoking observations, and activities | |
| Dietary Manager | Interviewed regarding menu substitutions and food ordering | |
| Environmental Manager | Interviewed regarding pest control and smoking assessments | |
| Maintenance Assistant | Interviewed regarding pest control and bedbug treatments | |
| Registered Nurse | Interviewed regarding dialysis care and fall investigations | |
| Dietary Cook | Observed substituting menu items without RD approval |
Inspection Report — Aug 29, 2019
Complaint Investigation
Date: Aug 29, 2019
Visit Reason
The inspection was conducted based on complaint allegations regarding staff treating a resident without dignity, infection control concerns, medication administration issues, and other care deficiencies.
Complaint Details
Complaint investigation revealed substantiated deficiencies related to resident dignity, infection control, medication administration, care planning, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity, inadequate environmental cleanliness, lack of accessible grievance forms, inaccurate resident assessments and care plans, improper medication documentation, unsafe resident transfers, inadequate wound care documentation, improper preparation of pureed foods, and failure to implement an effective infection prevention and control program.
Deficiencies (12)
Staff treated a resident with raised voice and forceful manner, causing distress and scratches.
Facility failed to maintain ceiling vents, sprinkler heads, and personal fans free of heavy dust buildup.
Grievance forms were not readily accessible to residents on the second floor and follow-up on grievances was inadequate.
Resident Minimum Data Set (MDS) assessments were inaccurate and did not reflect current medication or pain status.
Residents were not invited to participate in their quarterly care plan meetings and pain care plan was missing for one resident.
Resident's code status was not documented on Physician's Order Sheets and diet orders were not transcribed correctly.
Resident's surgical wound and diabetic foot ulcer were not properly documented, assessed, or monitored; outside wound care documentation was missing.
Resident was transferred unsafely without use of gait belt or mechanical lift as appropriate.
Dietary staff failed to properly prepare pureed foods according to recipe and lacked training documentation.
Resident's colostomy care was not routinely monitored or documented by nursing staff.
Resident's narcotic pain medication administration was not accurately documented, with multiple tablets unaccounted for.
Infection prevention and control program was deficient including lack of waterborne illness plan, improper storage of oxygen supplies, inadequate hand hygiene and infection control during blood glucose monitoring, and incomplete infection surveillance and antibiotic stewardship.
Report Facts
Residents affected: 49
Unaccounted Oxycodone tablets: 107
Unaccounted Tramadol tablets: 26
Pureed food processing time: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in dignity violation for raising voice and forceful behavior toward Resident #19 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including wound care, infection control, care planning, and medication documentation |
| DC A | Dietary Cook | Named in pureed food preparation deficiency and lack of training |
| CMT A | Certified Medication Technician | Named in infection control violations during blood glucose monitoring |
| LPN A | Licensed Practical Nurse | Named in medication and infection control deficiencies |
| Administrator | Facility Administrator | Interviewed regarding grievance process and infection control program |
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