Summit Acres Nursing Home

In the surveyor’s words

From the most serious findings on record at Summit Acres Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 26, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility incident and accident log and corresponding investigation, review of the Facility Assessment, review of the Elopement Risk Assessment Policy and Procedure and staff, family and resident interviews, the facility failed to provide adequate supervision to Resident #74, who was actively exit seeking, cognitively impaired (with a Brief Interview Memory Score of six indicating severe cognitive impairment), identified as an elopement risk and resided on the secured unit, to prevent the resident from exiting the secured unit and the facility unsupervised. […]

• Immediate jeopardy, isolatedF600Aug 16, 2021

  Based on closed record review, review of an emergency medical service (EMS) run report, facility Postmortem policy and procedure review, staff interview, family interview and interviews with Paramedic #202, Mortician #200 and Medical Director #401 the facility failed to provide adequate and immediate postmortem care to Resident #79 following the resident's death in the facility on [DATE] resulting in neglect of the resident's corpse. This resulted in Immediate Jeopardy, when on [DATE] at approximately 11:00 A.M. Resident #79's body was released to the funeral home without evidence of postmortem care having been provided. […]

• Immediate jeopardy, isolatedF678Aug 16, 2021

  Based on observation, closed record review, an Emergency Medical Service (EMS) squad run report, review of staff witness statements, review of the facility cardiopulmonary resuscitation (CPR) policy, review of the Association of Anesthetist's publication titled Multidisciplinary Guidelines for the Management of [CONDITION(S)] and Laryngectomy Airway Emergencies, staff interview, family interview and interviews with Paramedic #202, Medical Director #400 and Medical Director #401 the facility failed to initiate adequate cardiopulmonary resuscitation (CPR) for Resident #79 who had a [CONDITION(S)] tube and required supplemental oxygen. This resulted in Immediate Jeopardy on [DATE] at approximately 10:00 P.M. […]

• Actual harm, isolatedF686Sep 27, 2022

  Based on observation, record review, facility policy and procedure review and interview, the facility failed to prevent the development of an unstageable pressure ulcer and failed to ensure a pressure ulcer treatment was provided as ordered for Resident #50. Actual Harm occurred on 09/19/22 when Resident #50, who was cognitively impaired, high risk for skin breakdown and required extensive two person staff assistance for bed mobility was found to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right Achilles area. […]

• Actual harm, isolatedF684Aug 16, 2021

  Based on record review, review of a fall investigation report, review of the facility x-ray contract, facility policy and procedure review and interview the facility failed to ensure Resident #1 received timely and adequate care following a fall that resulted in an acute, traumatic, closed minimally displaced right intertrochanteric femoral fracture requiring surgical repair. Actual Harm occurred on 07/11/21 following a fall at 1:00 A.M. when the facility failed to immediately transport Resident #1 to the hospital or obtain a STAT x-ray which delayed hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was subsequently transferred to the hospital on 07/11/21 following an update to the nurse practitioner at 12:55 P.M. […]