Suites at Someren Glen Care Center, The

In the surveyor’s words

From the most serious findings on record at Suites at Someren Glen Care Center, The, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 25, 2024

  Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#1 and #27) of three residents out of 39 sample residents. Resident #27, who was known to be at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium (lower part of the pelvic bone that helps absorb weight when sitting) on 4/17/24. Resident #27's care plan documented the resident was to be offered repositioning at night during care and encouraged to lie in bed after lunch. Additionally, the resident was always incontinent of urine and frequently incontinent of bowel. […]

• Actual harm, isolatedF550Dec 1, 2022

  Based on record review and interviews, the facility failed to ensure the resident was treated with respect and dignity and care was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life and recognized the resident individuality for one (#1) resident out of five sample residents. Specifically, the facility failed to answer the resident's call light and provide services in a timely manner to the resident. The resident said it could be frustrating at times and he reacted with behaviors of becoming angry, calling out for help, and banging on walls. This caused the resident distress. Findings include: I. Resident status Resident #1, age 83, was admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF886Jan 30, 2023

  Based on interviews and record review, the facility failed to conduct testing in a manner that was consistent with current standards of practice for conducting COVID-19 tests for three (#1, #2, #3) of three residents reviewed out of four sample residents. Specifically, the facility failed to: -Document in the residents medical record the results of COVID-19 tests for all residents, and; -Document/log COVID-19 point-of-care/rapid testing or results for staff consistent with requirements. Findings include: I. Facility policy and procedure The Infection Prevention and Control policy and procedure, approval date December 2022, was provided by the assistant director of nursing (ADON) on 1/23/23 at 4:05 p.m. […]

• No harm, potential for more than minimal, widespreadF803Mar 31, 2022

  Based on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Follow correct portions sizes to ensure adequate nutrition were provided to the residents; and, -Follow recipe modifications for pureed, liquid pureed, and mechanically altered diets Findings include: I. Mechanically altered diets The Diet Manual was provided by the director of dining services (DDS) on 3/31/22 at 4:03 p.m. It revealed, in pertinent part, Regular diet, The diet is served when specific modifications are not required. Mechanical soft diet, the diet is a modification of the regular diet for the endentulours resident who has difficulty chewing or swallowing. […]

• No harm, potential for more than minimal, patternF552May 8, 2026

  Based on record review and interviews, the facility failed to ensure residents were informed of the treatment, including the risks and benefits, of proposed care and to choose the alternative option if they preferred for three (#4, #9 and #76) of six residents reviewed out of 51 sample residents.Specifically, the facility failed to: -Ensure Resident #4's consent explained the risks versus benefits for psychotropic medications; -Ensure Resident #9 and/or Resident #9's representative were informed and agreed to an increase in the dose of the resident's psychotropic medication; and, -Ensure Resident #76 and/or the resident's representative consented to antibiotic therapy prior to the administration of antibiotics.Findings include: I. […]