Signature Healthcare at Summerfield Rehab & Wellne

In the surveyor’s words

From the most serious findings on record at Signature Healthcare at Summerfield Rehab & Wellne, in the surveyor’s own words.

• Immediate jeopardy, patternF623Sep 20, 2024

  Based on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident or the resident's representative received adequate notice before transfer or discharge for four out of five residents (Resident (R) 3, R4, R13, and R14). The facility initiated a transfer/discharge based on the facility's inability to meet the resident's needs. However, upon complaint investigation, it was determined by interview and record review that the transfer/discharge was due to the facility needing to move the residents out of their rooms to make space for a new rehabilitation unit. Residents 3, R4, and R13 were selected based on their least likely to have a connection with the community. […]

• Immediate jeopardy, isolatedF880Jan 28, 2024

  Based on observation, interview, record review, review of the facility's fact sheet Preventing the Spread of Bloodborne Pathogens, review of the facility's online education course outline, Bloodborne Pathogens and the Use of Standard Precautions, review of Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, Microdot (brand) bleach wipes manufacturer's instructions, Cleaning and Disinfecting Recommendations,'; review of the facility's internal resource Common Infections, PPE & Isolation Guidelines,; review of the CDC's Enhanced Barrier Precaution (EBP) door signage, and review of the facility's policies, it was determined the facility failed to implement recommended interventions for the cleaning and disinfecting of a shared glucometer (glucose… […]

• Actual harm, isolatedF689Sep 20, 2024

  Based on observation, interview, record review, and facility policy review it was determined, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one for 30 sampled residents, Resident (R) 1. R1 sustained a fall between 04/16/2024 and 04/18/2024. Interviews and record review revealed staff failed to follow the resident's care plan which instructed staff to utilize the mechanical lift when transferring the resident from her bed to wheelchair. […]

• Actual harm, isolatedF656Jan 28, 2024

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs for nine (9) of seventy-one (71) sampled residents (Residents #1, #4, #11, #39, #41, #48, #59, #325, and #381). Resident #59's care plan had interventions to provide incontinence care, which staff failed to implement causing emotional distress. Resident #41's care plan had interventions for falls. However, observations revealed these interventions were not implemented. […]

• Actual harm, isolatedF677Jan 28, 2024

  Based on observation, interview, record review, review of the facility's job descriptions, and review of the facility's policy, it was determined the facility failed to provide necessary services to a resident who was incapable of carrying out activities of daily living to maintain personal hygiene for one (1) of seventy-one (71) sampled residents (Resident #59). Resident #59 was dependent on staff to perform toileting hygiene; staff failed to change Resident #59's briefs timely resulting in the resident experiencing emotional distress, crying because he/she was left laying in a bed soaked with urine. […]