San Simeon By The Sound Center for Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at San Simeon By The Sound Center for Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Sep 5, 2024

  Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility failed to ensure the residents' environment remained free of accident hazards. This was evident at the resident sinks and common shower rooms on all 4 of 4 resident units. Specifically, the facility failed to protect all 114 residents from the likelihood of burns related to excessive hot water temperatures from the facility's domestic hot water system. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy and Substandard Quality of Care to all residents' health and safety. […]

• Immediate jeopardy, isolatedF609Dec 26, 2023

  Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY00329617), the facility failed to ensure that two allegations of sexual abuse were reported to the Department of Health and Local Law Enforcement within two hours. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. […]

• Immediate jeopardy, isolatedF610Dec 26, 2023

  Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY00329617), the facility failed to ensure that two allegations of sexual abuse were investigated. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. […]

• Actual harm, isolatedF689Nov 23, 2022

  Based on observations, record review, and staff interviews during the Recertification Survey initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #31) of eight residents reviewed for accidents. Specifically, Resident #31, required supervision at all times and was not to be left alone in their room as per their Comprehensive Care Plan (CCP). Resident #31 had an unwitnessed fall in their room on 10/11/2022 when a Certified Nursing Assistant (CNA) #4 left the resident unsupervised in their room and exited the room. Resident #31 fell out of the wheelchair and sustained a C 1 Cervical fracture. […]

• No harm, potential for more than minimal, patternF584Sep 5, 2024

  Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all residents were provided a safe, clean comfortable, and homelike environment. This was identified for two (B Unit and [NAME] Unit) of four units reviewed during the environmental task; and for two residents (Resident #48 and Resident #100) of three residents reviewed for the environment task. Specifically, 1) the suction machine on the [NAME] Unit dining room was observed with used suction tubing and a dirty suction canister that contained cloudy fluid with food particles, and 2) the privacy curtains for Resident #47 and Resident #100 were observed to be soiled. […]