Summerford Health and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Summerford Health and Rehab, LLC, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 24, 2024

  Based on record reviews, interviews, the facility's incident report, the facility's investigation titled, INVESTIGATION TEMPLATE, and the facility's policy titled, Abuse Prevention Program, the facility failed to protect Resident #403's right to be free from physical abuse by having inadequate staff to supervise residents. On 01/09/2023 at approximately 3:45 AM, Certified Nurse Assistant (CNA) #32 responded to Resident #403's room and observed him/her lying in bed with blood coming from a laceration to the face. Upon investigation, it was determined that residents were left unsupervised on the secured (locked) unit and staff failed to prevent Resident #404 from repeatedly striking Resident #403 with his/her cane. […]

• Actual harm, isolatedF725Apr 24, 2024

  Based on record reviews, interviews, document reviews, and policy review, the facility failed to ensure sufficient staff were available to provide supervision for residents on the facility's secured unit during the night shift. On 01/09/2023 at approximately 2:30 AM, staff left residents on the [NAME] Haven Unit (a locked, secured unit where 24 residents resided) unsupervised to take care of residents on other units because there was an insufficient number of staff. While the locked/secured unit was unsupervised, Resident #404 struck their roommate, Resident #403, with a cane which resulted in a facial laceration, facial bruising and swelling, and multiple other injuries to the resident's body. This failure affected one of nine units in the facility. […]

• Actual harm, isolatedF725Sep 15, 2023

  Based on record reviews, interviews, document reviews, and policy review, the facility failed to ensure sufficient staff were available to provide supervision for residents on the facility's secured unit during the night shift. On 01/09/2023 at approximately 2:30 AM, staff left residents on the [NAME] Haven Unit (a locked, secured unit where 24 residents resided) unsupervised to take care of residents on other units because there was an insufficient number of staff. While the locked/secured unit was unsupervised, Resident #404 struck their roommate, Resident #403, with a cane which resulted in a facial laceration, facial bruising and swelling, and multiple other injuries to the resident's body. This failure affected one of nine units in the facility. […]

• No harm, potential for more than minimal, patternF880Sep 15, 2023

  Based on observation, interview, and facility policy and document review, the facility failed to ensure staff appropriately used and discarded personal protective equipment (PPE) for three (Residents #308, #38, and #47) of three residents reviewed who had transmission-based precautions implemented. These residents lived on three of six halls where residents resided. Resident #308 tested positive for coronavirus disease 2019 (COVID-19) and required contact and droplet precautions. Resident #38 and Resident #47 were identified as requiring enhanced barrier precautions. Findings included: A review of the facility policy titled, Infection Prevention and Control Program Policy, with a revision date of 01/20/2023, indicated, . […]

• No harm, potential for more than minimal, isolatedF609Sep 15, 2023

  Based on interviews, record reviews, facility policy and document review, the facility failed to ensure a Certified Nursing Assistant (CNA) reported an allegation of abuse to administration immediately, or within two hours. On 02/23/2023, CNA #2 allegedly observed CNA #1 being rough and verbally inappropriate while providing care but did not report the allegation to the Administrator until 02/27/2023 at 1:15 PM, four days later. This failure affected three (Residents #40, #114, and #139) of five sampled residents reviewed for abuse. Findings included: A review of a facility policy titled, Abuse Investigation and Reporting, revised April 2019, revealed, . Abuse or Neglect is to be reported immediately to the supervisor, who then will report to the Administrator. […]