Aperion Care Summerfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the code status of a resident was accurate for the physician order, careplan, and POST (physician's order for scope of treatment) form for 1 of 17 records reviewed. (Resident 24) Findings include: On [DATE] at 11:21 a.m., the medical record of Resident 24 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress) and dysphagia (difficulty swallowing). A physician order, dated [DATE], indicated that the resident chose to be a full code (to provide full resuscitation in the event of the need for life saving measures). A POST form (Physician Orders for Scope of Treatment form is a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 of 11 residents MDS assessments reviewed (Resident 32). Findings include: During an interview, on 4/30/25 at 9:57 a.m., Resident 32 denied that she had a feeding tube for nutritional intake. She indicated that she had never had one. Resident 32's record was reviewed on 5/2/25 at 9:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), dysphagia, unspecified (refers to medical term for difficulty swallowing), and nutritional deficiency (lack of sufficient nutrients in the body). A quarterly MDS assessment, dated 4/25/25, indicated the resident had a feeding tube (a medical device used to deliver nutrition and fluids directly into the digestive system, bypassing the mouth and esophagus). A physician order, dated 10/7/24, indicated a regular diet, mechanical soft (foods that have been altered in texture to make them easier to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure quarterly care plan meetings, which addressed the specific needs of the Resident were completed for 1 of 16 residents reviewed (Resident 29). Findings include: On 5/1/25 at 9:32 a.m., during an initial interview, Resident 29 did not recall attending care plan meetings which addressed his specific needs. On 5/1/25 at 1:00 p.m., the medical record of Resident 29 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), and epilepsy (a disorder of the brain characterized by repeated seizures). An annual Minimum Data Set (MDS) assessment, dated 3/15/25, indicated the resident was cognitively impaired. A comprehensive care plan addressing the resident's needs, initiated on 3/27/24, was reviewed and updated accordingly. The medical record lacked documentation of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure water temperatures in the dining room wash station and common restrooms were within safe parameters for 3 of 3 random observations. Findings include: On 4/30/25 at 11:51 a.m., while observing the staff washing their hands during meal service, noted the water was very hot and staff had to continually adjust the water. The water temperature was 143 degrees in the main dining room kitchen sink. During two observations one at 10:00 a.m. and again at 2:05 p.m., the door to the common restroom on the south hall was unlocked. The water temperature was 135.5 degrees. During observation of the south hall resident room and shower room indicated, the water temperature in the south hall shower and sink was 119 degrees. Resident rooms on both halls observed water temperatures were within acceptable parameters. On 4/30/25 at 2:39 p.m., during interview the Administrator indicated the water in the employee restroom was connected to the main kitchen. She was not aware the door was unlocked and indicated a visitor must have left it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 1 of 2 dining observations. Findings include: 1. During a dining observation, on 4/30/25 at 11:55 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to a table and adjusted a resident in their wheelchair, so she was closer to the table. 2. During a dining observation, on 4/30/25 at 11:56 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to wait at the counter for the lunch trays to be ready to be served, pulled on the back of her t-shirt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage 8 hours per day 7 days per week for 7 of 28 days reviewed for staffing. This had the potential to affect 40 of 40 residents who resided in the facility. Findings include: On 4/30/24 at 11:00 a.m., review of RN staffing schedules for 4/1/24 to 4/27/24 indicated the Director of Nursing was scheduled as the RN Monday through Friday. An RN was not scheduled for the weekends of 4/6/24, 4/7/24, 4/12/24, 4/13/24, 4/19/24, 4/20/24, or 4/28/24. The Administrator indicated the Director of Nursing was available for calls during the weekends. On 4/30/24 at 11:45 a.m., the Administrator provided a document titled, Staffing, dated 2001, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement .Our facility provides adequate staffing to meet needed care and services for our resident population .1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a call light was kept within the resident's reach for 1 of 16 residents reviewed for call lights (Resident 39). Finding includes: On 4/25/24 at 9:22 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/26/24 at 8:55 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 9:02 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 3:15 p.m., the Director of Nursing (DON) observed the call light under the two storage containers and indicated, Resident 39's call light should be within reach and not on the floor under the two storage containers. Resident 39's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff wore a hairnet restraint when in the kitchen, hand hygiene was completed appropriately, food items were labeled and dated, expired foods were discarded, dented cans were not stocked for usage for the residents' meals, and food was not stored directly onto the storeroom floor for 1 of 2 kitchen observations. This deficiency had the potential to affect 40 of 40 residents who received food from the kitchen. Findings include: During an initial tour of the kitchen with the Dietary Manager (DM), on 4/24/24 at 9:50 a.m., the following was observed: a. While in the kitchen, the DM had her hair in a ponytail without a hairnet and failed to wash her hands prior to beginning the kitchen tour and handling food items. b. The kitchen freezers contained an undated bag of biscuits, 2 undated bags of frozen French fries, 3 undated lemon pies, 2 undated bulk sausage tubes, 6 undated packages of waffles, 2 packages of puree peas labeled with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the laminate flooring (a multi-layer synthetic flooring product) in the facility was safe in good repair, for 5 of 5 days the facility environment was observed. Findings include: During a random observation, on 2/6/23 at 2:28 p.m., a mat on top of the laminate flooring at the entrance to the television (TV) lounge next to the nurse's station, appeared to move when stepped on. Upon request, the Administrator (ADM) lifted the rug and exposed a large area where the laminate flooring was broken and no longer stable on the subfloor (a rough floor laid as a base for a finished floor) and was sliding back and forth in place. The entire piece of a single laminate floor plank was loose and broken. Each surrounding plank of the flooring, around the initial broken area, were also beginning to become loose. Areas of exposed subfloor were visible around the broken area of the planks. Along the area of the hallway leading to mat was observed to have gaps between the laminate floor planks. A single large, gapped area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure psychotropic medications (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had been documented as administered for 4 of 11 residents medications reviewed (Residents 30, 9, 40, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), mood affective disorder (mental disorders that primarily affect a person's emotional state), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder), generalized anxiety disorder (a condition of excessive worry about everyday issues and situations), and depression (persistent sadness and a lack of interest or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe food temperatures as evidenced by inadequate external and internal temperatures for 1 of 4 reach in refrigerators and the facility failed to dispose of expired food for 2 of 2 kitchen observations. This had the potential to effect 40 of 40 residents who received food from the kitchen. Findings Include: During an initial tour observation of the kitchen with Dietary Supervisor (DS), on 02/06/2023 at 09:50 a.m., the inside thermometer temperature was reading 48 degrees Fahrenheit (F) on reach in refrigerator # 3. No internal temperature of food was taken at that time. The reach in refrigerator contained 2 containers of heavy whipping cream, bags of shredded cheese, boxes of stick butter, and containers of sour cream. Inside freezer # 2 there were 3 frozen concentrated grape juice containers. They were dated April 15, 2020, May 15, 2020, and May 23, 2020. During an interview with DS on 02/06/2023 at 09:50 a.m., she indicated the reach in refrigerator had too much food in it and that was the reason it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure medications had been documented as administered for 3 of 5 residents reviewed for unnecessary medications (Residents 30, 9, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and unspecified leg pain. An annual Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had moderate cognitive deficit and received routine pain medications. A care plan, dated 12/30/22, indicated the resident has alterations in comfort related to leg pain. Interventions included, but were not limited to administer medications as ordered. A review of the resident's December 2022, January 2023, and February 2023, medication administration records (MAR) indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.