Summerstone Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Summerstone Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF835Oct 8, 2021

  Based on observations, staff interviews and record reviews, the facility failed to provide orientation and education to nursing staff on the availability of individual blood glucose monitors (glucometers) assigned to each resident requiring blood glucose monitoring. The facility also failed to provide education on how to disinfect a shared glucometer used for multiple residents in accordance with the manufacturer's instructions. This was evident for 1 of 1 nurse (Nurse #1) observed who was new to the facility and worked independently as a hall nurse assigned to care for residents. […]

• Immediate jeopardy, patternF880Oct 8, 2021

  Based on observations, staff interviews, and record review, the facility staff failed to use an approved disinfectant product and procedure to clean and disinfect a shared blood glucose meter (glucometer) used for 6 of 6 residents (Resident #1, #2, #3, #4, #5 and #6). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of blood borne infections. […]

• Immediate jeopardy, isolatedF689Mar 3, 2025

  Based on record review and staff, Nurse Practitioner (NP), and Responsible Party (RP) interviews, the facility failed to protect a cognitively impaired resident, Resident #6, when he was allowed to exit the facility through the locked main entrance door. Nurse Aide (NA) #1 unlocked and opened the door for Resident #6 and allowed him to leave the facility, in the dark, on the evening of 1/26/25. Resident #6 was found in the parking lot of a restaurant near a gas station 1.4 miles from the facility. There were multiple roads between the facility and where the resident was found including a divided 4 lane road, a 4-lane highway, sidewalks, posted speed limits of up to 45 miles per hour, in 38-degree Fahrenheit weather while wearing shoes, pajamas, a coat, and a hat. […]

• Immediate jeopardy, isolatedF689Feb 2, 2023

  Based on resident and staff interviews, Nurse Practitioner (NP) and hospital radiologist interviews, and record reviews, the facility failed to transfer a resident safely from her recliner to the bathroom toilet with the assist of one while using a sit-to-stand lift for 1 of 2 residents reviewed for accidents (Resident #4). Resident #4 experienced a fall when the nurse aide did not fasten the sling's chest support strap securely in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift resulting in the resident falling from the lift to the floor. […]

• Immediate jeopardy, isolatedF726Feb 2, 2023

  Based on resident and staff interviews and record review, the facility failed to provide agency Nurse Aides (NA #1 and NA #2) with orientation and training to meet individual residents' care needs, including education and verification of the NA's competency on the safe use of the facility's mechanical sit-to-stand lift. One (1) of 2 residents reviewed for accidents (Resident #4) experienced a fall when the nurse aide did not fasten the sling's chest support strap in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift. The resident fell from the lift to the floor. […]