Signature Healthcare at Summit Manor Rehab & Welln

In the surveyor’s words

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

• Immediate jeopardy, isolatedF657May 4, 2021

  Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of four (4) sampled residents (Resident #1) when the resident exhibited increased wandering and exit seeking behavior symptoms. Following admission on 02/12/2021, the facility addressed Resident #1's elopement risk on the resident's plan of care. The facility readmitted the resident on 03/04/2021 and review of the progress notes revealed the resident displayed wandering and/or exit seeking behaviors twenty (20) times between 03/04/2021 and 03/26/2021. However, the facility failed to revise the resident's plan of care to address the exit seeking and increase in wandering behavioral symptoms. […]

• Immediate jeopardy, isolatedF689May 4, 2021

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of four (4) sampled residents (Resident #1). The facility identified Resident #1 to be at risk for elopement and placed a Wanderguard alarm bracelet on the resident on 02/12/2021 (after the resident's original admission). On 3/26/2021, at approximately 11:00 PM, staff heard an exit alarm sounding. The staff member who heard the alarm, disabled the alarm; however, failed to follow the facility policy and procedure to determine if a resident had eloped from the facility. […]

• Actual harm, isolatedF697Mar 26, 2026

  Based on observation, interview, record review and facility policy review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one of 25 sampled residents (Resident (R)22).The findings include: Review of the facility's policy titled Pain Management' last reviewed 01/31/2026, revealed the facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. […]

• No harm, potential for more than minimal, patternF921Mar 26, 2026

  Based on observation, interview, and review of the facility's policy, the facility failed to provide a safe, clean, and well-maintained environment. Multiple maintenance concerns were observed throughout the facility that had the potential to all residents. The findings include:Review of the facility's policy titled Home-like Environment, last revised 09/05/2025, revealed the resident has a right to a safe, clean, and homelike environment.Observation, on 03/24/2026 at 8:34 AM, revealed a handrail leading into the kitchen that was not securely attached, with screws coming out of the wall. Also, there was a separate handrail end which was not attached securely to the wall mount and jiggled. […]

• No harm, potential for more than minimal, isolatedF812Mar 26, 2026

  Based on observation, interview, and review of facility policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety.The findings include:Review of the facility policy titled, Grooming and Dress Policy, undated, revealed under no circumstance may employees wear oversized clothing. All clothing must be clean, neat, and fit properly.Review of the facility policy titled, Warewashing, last revised 02/2023, revealed all dishware will be air dried and properly stored.On 03/26/2026 at 10:00 AM, the State Survey Agency (SSA) Surveyor asked the Director of Nursing (DON) to provide policies regarding infection control/hand hygiene and glove use/Personal Protective Equipment (PPE) for dietary staff; however, no such policies or… […]