Signature Healthcare at Summit Manor Rehab & Welln

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, the facility failed to provide a safe, clean, and well-maintained environment. Multiple maintenance concerns were observed throughout the facility that had the potential to all residents. The findings include:Review of the facility's policy titled Home-like Environment, last revised 09/05/2025, revealed the resident has a right to a safe, clean, and homelike environment.Observation, on 03/24/2026 at 8:34 AM, revealed a handrail leading into the kitchen that was not securely attached, with screws coming out of the wall. Also, there was a separate handrail end which was not attached securely to the wall mount and jiggled. Observation on 03/24/2026 at 9:05 AM; 03/25/2026 at 2:45 PM; and 03/26/2026 at 7:25 AM, revealed a water hose lying in the flowerbeds at the entrance to the facility. A white styrofoam cup was observed on the ground outside of a resident's window. Observation, on 03/24/2026 at 9:36 AM, revealed the entry door to the kitchen…

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 review of the facility's policy, it was determined the facility failed to prepare, distribute, and serve food in a sanitary manner and in accordance with professional standards for food service safety. Dietary staff failed to wash hands and change gloves prior to preparing resident foods and failed to check the temperatures of seven of ten food items on the steam table during the dinner meal on 01/21/2025. The findings include: Review of the facility's policy titled, Food: Preparation revised 09/2017, revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. Per the policy, all staff would practice proper hand washing techniques and glove use and the staff would be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Further review of the policy revealed, all utensils, food contact equipment, and food contact surfaces were required to be cleaned and sanitized after every use. An observation on 01/21/2025 at 5:26 PM,…

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 interview, record review, and review of the facility policy, it was determined the facility failed to provide two (2) of twenty-eight (28) sampled residents (Resident #57 and Resident #79) with notification regarding bed hold upon transfer out of the facility. Residents #57 and #79 did not receive notifications regarding bed hold when transferred to an acute care hospital. The findings include: Review of the facility policy, Facility Bedhold, dated 11/12/18, revealed the facility would notify the resident/responsible party of the facility's bed hold and readmission policies at time of admission and anytime a resident is transferred to the hospital or goes out on therapeutic leave. The policy further stated the facility would provide a written notice of the bed hold and readmission policies before a resident's transfer to the hospital or for overnight therapeutic leave. 1. Observation of Resident #57 on 10/15/19 during initial tour at approximately 12:00 noon, revealed the resident lying on his/her back…

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, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined that the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for one (1) of thirty-two (32) sampled residents (Resident #20). Resident #20 was observed to have limited range of motion to bilateral upper and lower extremities that was not coded on the MDS. The findings include: Review of the facility policy titled Resident Assessment, review date 07/31/18, revealed on page 1, The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the Resident Assessment Instrument page G-37 revealed specific steps to test the resident's upper and lower extremities for range of motion. For each hand, instruct the resident to make a fist and then open their hand. Review of Resident #20's medical record revealed the resident was admitted to the…

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, record review, and facility policy review it was determined that the facility failed to develop a person-centered care plan for one (1) of thirty-two (32) sampled residents (Resident #20) that met the resident's needs. Resident #20 was observed to have limited range of motion to bilateral upper and lower extremities that was not addressed on the resident's care plan. The findings include: Review of the facility policy titled Comprehensive Care Plans, reviewed 07/19/18, revealed on page 1, The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to the Resident Assessment Instrument. Review of the Resident Assessment Instrument page G-37 revealed specific steps to test the resident's upper and lower extremities for range of motion. Review of #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Rheumatoid Arthritis, Heart Disease, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined the facility failed to ensure expired medication was not available for use and was identified timely and removed from the current medication supply. Observation of the nurses cart on Sunset Blvd. on [DATE] at 11:34 AM revealed an open bottle of Humulin R dated as opened on [DATE] for unsampled Resident #72. Review of Resident #72's Physician's Orders revealed Humulin R insulin had been discontinued on [DATE]. The findings include: Review of facility policy, Medication Administration, dated [DATE], revealed the policy did not address insulin but on Page 4, Section 8.c stated, Certain products or package types such as multi-dose vials and ophthalmic drops have specific shortened end-of-use dating once opened, to ensure medication purity and potency (Refer to Section 9.10-Medication With Shortened Expiration Dates). Further review of the policy revealed there was no Section 9.10. Further review of the facility policy, Medication Administration,…

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 interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of one (1) resident assessment was transmitted within 14 days after Resident #1's discharge to an acute care hospital on [DATE], with no return anticipated. The findings include: Review of the facility's policy, Resident Assessment, with a revision date of June 2017, revealed a return not anticipated Minimum Data Set (MDS) discharge assessment would be transmitted within fourteen (14) days of the completion date. Review of Resident #1's medical record revealed the facility admitted the resident on 04/29/18, with diagnoses including Diabetes Mellitus. Review of Resident #1's discharge MDS completed by the facility on 05/20/18, revealed the resident had been discharged from the facility to an acute care hospital on [DATE], with no return anticipated. However, there was no evidence the facility had transmitted the assessment as of 09/13/18. Interview conducted with the MDS Coordinator on 09/13/18…

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 interview, record review, and facility policy review, it was determined the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for one (1) of twenty-five (25) sampled residents. Resident #6 was diagnosed with Schizophrenia on 06/13/18; however, the facility failed to ensure a Level II PASARR assessment was completed. The findings include: Interview with the Director of Nursing revealed the facility did not have a policy regarding the completion of PASARR assessments. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia without Behavioral Disturbance, Anxiety Disorder, Cerebrovascular Disease, Visual Hallucinations, Hemiplegia affecting Left Nondominant Side, and Arthropathy. Further review of the resident's medical record revealed a Level I PASARR was completed for Resident #68 on 09/30/08. Further review revealed Resident #68 received a new diagnosis of Schizophrenia…

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, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of twenty-five (25) sampled residents related to bowel and bladder. The facility staff failed to provide the assistance Resident #63 required for bed mobility as required on the Comprehensive Care Plan. The findings include: Review of the facility policy titled, Comprehensive Care Plans, not dated, revealed a person-centered Comprehensive Care Plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident and included how the facility would assist the resident to meet their needs, goals, and preferences. Review of Resident #63's medical record revealed the facility admitted the resident on 07/22/13 with diagnoses that include Chronic Obstructive Pulmonary Disease, Pleural Effusion, Pneumonia, Flaccid Hemiplegia affecting Left Nondominant Side, Heart Failure, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and a review of the facility's incontinence care policy, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents (Resident #59) with urinary incontinence received appropriate treatment and services to prevent urinary tract infections. Observation revealed staff failed to provide incontinence care for Resident #59 on 09/12/18 in accordance with the facility's policy. The findings include: A review of the facility's policy titled Perineal Care Male or Female, undated, revealed the penis and scrotum were required to be cleaned and dried for male residents who were incontinent. A review of the medical record for Resident #59 revealed the facility admitted the resident on 01/26/18 with diagnoses that included Dementia, Chronic Back Pain, Transient Ischemic Attacks, and Urinary Retention. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be frequently…

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, record review, and review of the facility policy it was determined the facility failed to maintain the kitchen environment and equipment in a sanitary manner. Observation revealed the drip pan on the range had a buildup of food debris and dried stains, the can opener had a buildup of dried food debris on the cutting blade and stains on the base of the unit, and the bottom of the plate warmer was soiled with food and liquid stains. The findings include: 1. Review of the facility's kitchen sanitation policy, dated 02/19/15, revealed the drip pan underneath the range top was to be removed and cleaned after each evening shift. Observation of the drip pan under the range top at 8:35 AM on 09/11/18 revealed the drip pan was soiled with a buildup of food debris and burnt grease. Review of the weekly cleaning schedule revealed the range drip pan had been cleaned on Friday (no date or initials) and was wiped off on Monday (no date or initials). Interview with the Dietary Manager (DM) at 8:40 AM CDT on 09/11/18 revealed it had been a few days since the range…

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, record review, and a review of the facility policy it was determined the facility failed to maintain an infection control program to prevent the development and transmission of infectious disease for two (2) of twenty-five (25) sampled residents (Resident #15 and Resident #70). Staff failed to utilize standard precautions of changing gloves and performing hand hygiene after performing incontinence care for Resident #15 and performing wound care treatment for Resident #70. The findings include: A review of the facility's infection control policy titled Standard Precautions, with a revision date of December 2007, revealed staff were required to change gloves and perform hand hygiene as necessary during care of a resident to prevent cross-contamination and when performing wound care and moving from a dirty site to a clean site. 1. A review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Dementia, Cerebral…

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.