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Inspection visit

Routine inspection (multi-day)

SUMMER SPRINGS BOARD & CARELicense 15720422113 citations on this visit
13 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Socorro Telmo. During yesterday's visit LPA's toured the facility. LPA Doucette observed 4 bedrooms in the facility. While touring the facility, LPA observed an added staff bedroom/office/garage which was not on the facility sketch and was not fire cleared. Facility had two different facility sketches posted in the facility. The first sketch did not identify a caregiver room. The second sketch identified the caregiver room as bedroom 1 where residents reside. LPA pulled the sketch from licensing file which does not identify a caregiver room. The staff bedroom/office/ garage contained a fully made bed with sheets and blanket, a recliner and filing cabinets. Facility did not have plan of operation at the facility. Hot water temperature was measured 115 F. Bathroom did not have skid mats but had grab bars. Facility staff purchased skid mats during visit. Kitchen toured, supply of food observed. Carrots were expired October 2023. Knives were locked in kitchen drawer. Medications were stored in a Medication cart which was found to be unlocked in the dining room. Refrigerator for medications were found to be unlocked containing morphine and insulin in the dining room. LPA's took photos. Cleaning supplies were in a locked cabinet under the kitchen and bathroom sinks. Smoke detectors and carbon monoxide detectors were checked and operating. Resident, medication, and staff records were reviewed. R3's centrally stored log was reviewed and errors were observed. One of R3's narcotic medications was not logged. R1's records were reviewed and it was found that R1 self administers injections. R1 had a sharps container in a shared room with R2, which made sharps accessible to R2. Facility does not have a Home Health Care Plan for R2. Facility did not have a Hospice Care Plan for R4. Staff have current first aid and CPR training. Staff did not have training logged correctly. Training was missing hours and dates. Facility staff did not have training from Hospice for R4. Administrator was not able to provide intial staff training for staff. During today's visit Administrator was able to provide plan of operation and plan of operation for dementia. LPA rechecked the medication cart and two drawers were unlocked with medication. LPA took photos. LPA educated Licensee/Administrator on where to locate care tool to assist Licensee/Administrator in becoming compliant. Refer to 809D for deficiencies. Civil Penalties were issued for repeat violations. An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeal rights were discussed and left with the Administrator, Socorro Telmo, whose signature on this form confirms receipt of these documents.

Citations

13 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87405(d)Type A

    Required administrator qualifications listed in this subsection

    Based on observation interview record review, the licensee did not comply with the section cited above due to the amount of citations Administrator is not meeting the requirements of this regulation, which poses an immediate health, safety or personal rights risk to persons in care.

  • 1569.725(a)(4)Type B

    Based on observation interview) record review, the licensee did not comply with the section cited above in Licensee did not have a home health care plan for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    Based on observation, interview and record review, the licensee did not comply with the section cited above in having a staff room/office in the garage that is not fire cleared, which poses an immediate health, safety or personal rights risk to persons in care. LPA took photos.Cvil Penalty issued.

  • 87303(f)(2)Type A

    Handle syringes and needles under bloodborne pathogen rules

    Based on observation, the licensee did not comply with the section cited above by licensee having a syringe box that is in R1's shared room with R2 accessible to R2, which poses an immediate health, safety or personal rights risk to persons in care.

  • 87411(d)(1)Type B

    Based on observation interview record review, the licensee did not comply with the section cited above by not having a plan for daily meals for residents with modified diets, facility staff could not answer what residents were eating for dinner which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(a)(6)Type B

    Maintain records of centrally stored medication dosages

    Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have a bottle of oxycodone logged on centrally stored log which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(2)Type A

    Store centrally held medications in locked secure place

    Based on observation the licensee did not comply with the section cited above in by not having the medication cart locked and not having the medication refridgerator locked containing morphine and insulin which poses an immediate health, safety or personal rights risk to persons in care.

  • 87555(b)(7)Type B

    Modified diets for medical necessity

    Based on observation interview record review, the licensee did not comply with the section cited above by Licensee not having a diabetic diet for R1 and a low sodium diet for R3 which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87555(b)(8)Type B

    Food quality controls and rejected damaged goods

    Based on observation, the licensee did not comply with the section cited above by having bags of expired carrots expiring 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87609(b)(4)Type B

    Agree in writing on agency and facility responsibilities

    Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have in writing the responsibilities of Home Health and the responsibilities of facility staff for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87633(a)(4)Type B

    Each terminal resident needs a written hospice care plan

    Based on record review, the licensee did not comply with the section cited above in R4 not having a Hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87633(b)(6)Type B

    Based on record review, the licensee did not comply with the section cited above Licensee did not have training for R1's diabetic diet or for R4's medical conditions, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87633(h)(5)Type B

    Based on record review, the licensee did not comply with the section cited above by licensee not having an agreement signed by R2 for a shared room with R1 who is on Hospice which poses/posed a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 17, 2024 inspection of SUMMER SPRINGS BOARD & CARE?

This was an other inspection of SUMMER SPRINGS BOARD & CARE on April 17, 2024. 13 citations were issued: 4 Type A (serious) and 9 Type B.

Were any citations issued to SUMMER SPRINGS BOARD & CARE on April 17, 2024?

Yes, 13 citations were issued (4 Type A, 9 Type B). The first citation was for: "Based on observation interview record review, the licensee did not comply with the section cited above due to the amount..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.