Summers Healthcare, LLC

In the surveyor’s words

From the most serious findings on record at Summers Healthcare, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 24, 2024

  On 01/18/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide Resident #1 with an environment that was free from accident hazards. A nurses' note, written 01/03/24 at 5:40pm, documented resident was found with left arm caught in bed rail and the bed rail had fallen on it. A nurses' note, written 01/04/24 at 3:28pm, documented the resident was transferred to the ER following xray of left arm. An ER report, dated 01/04/24, documented resident had a closed fracture of the left distal humerus. On 01/17/24 at 12:10pm, the resident was observed in bed with two upper bed rails raised. On 01/18/24 at 1:10pm, the DON acknowledged no physician's orders and no bed rail risk assessment had been completed. […]

• No harm, potential for more than minimal, widespreadF680Jan 24, 2024

  Based on interview and record review, the facility failed to have a qualified activity director for 19 of 19 residents who resided at the facility. Findings: On 01/18/24 at 1:10 p.m., the DON was asked if the facility had a certified activity director. She stated not at this time, CMA #1 does activities when they are here and comes in on their days off, the rest of the staff pitches in too. The DON was asked if CMA #1 or any other staff were certified activity directors. They stated no. On 01/18/24 at 3:56 p.m., the Administrator reported the last day the facility had a certified activity person was on 07/31/23.

• No harm, potential for more than minimal, patternF604Jan 24, 2024

  Based on record review and interview, the facility failed to develop and implement interventions for reducing or discontinuing the use of bed rails and provide ongoing monitoring and evaluation for three (#1, 3, and #4) of three sampled residents with bed rails in use. The administrator identified 19 residents resided in the facility. There were six residents with bed rails in use. 1. Resident #1 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 12:10 p.m., Resident #1 was observed in bed with two upper bed rails raised. 2. Resident #3 had diagnoses that included gastrostomy, tracheostomy, and ventilator dependent. On 01/17/24 at 1:08 p.m., Resident #3 was observed in bed with four bed rails raised. 3. […]

• No harm, potential for more than minimal, patternF700Jan 24, 2024

  Based on record review and interview, the facility failed to a. assess the resident for need and safety of bed rail use, b. discuss the risks and benefits of bed rails and obtain informed consent from the resident or the resident's representative, and c. obtain a physician's order for the use of bed rails for three (#1, 3, and #4) of three sampled residents reviewed for restraints. The administrator identified 19 residents resided in the facility. There were six residents with bed rails in use. Findings: A Restraints (Physical) policy, undated, read in parts, .Procedure .1. Assess resident's need for restraint use .Obtain informed consen .Obtain physician's order .Develop or review resident care plan . 1. […]

• No harm, potential for more than minimal, patternF640Aug 25, 2023

  Based on record review and interview, the facility failed to ensure MDS assessments were transmitted timely for three (#152, 104, and #154) of 11 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents report, dated 08/23/23, documented 19 residents resided in the facility. Findings: A MDS 3.0 Validation Report, dated 08/23/23, documented the following comprehensive assessments were not transmitted within 14 days of completion: a. Resident #152's comprehensive assessment, dated 05/19/23, b. Resident #104's comprehensive assessment, dated 12/16/22, and c. Resident #154's comprehensive assessment, dated 01/27/23. On 08/24/23 at 3:00 p.m., the administrator was asked to provide MDS submission reports from April 2023 to August 22, 2023. […]