Summers Healthcare Center

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure residents received physician-ordered therapeutic diets by not providing honey-thickened liquids at the correct consistency. This deficient practice was identified for 1 of 1 residents reviewed for therapeutic diets (Resident #98). The State Agency determined this to be an Immediate Jeopardy situation as the failure created a likelihood for serious harm, aspiration pneumonia, and/or death. Resident identifier: #98. Facility census: 102. Findings Include:a) Resident #98An observation on 08/19/25 at 11:00 AM revealed the following:Resident #98's bedside cup of water dated 8/19/25 thickened was observed. The liquid did not appear to meet the required honey-like (moderately thick) consistency. The record review on 08/19/25 revealed the following:Physician orders for Resident #98 directed: [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide the necessary care and services to recognize and treat changes in condition, follow physician's orders for medication parameters, document medication administration, and provide food in the correct form. Resident #93 suffered actual harm after the facility failed to identify and timely treat a change in condition resulting in the resident being hospitalized with Respiratory Failure, Urinary Tract Infection , and Aspiration Pneumonia. Resident #110 suffered actual harm at the facility when she died of a food bolus when she was given hamburger at the facility despite having an order for nothing by mouth. Even though the facility did not serve the resident the meal they failed to protect the resident from others providing her with food. [...]

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to assess, monitor and treat pain in accordance with professional standards of treatment. For Resident #85 this resulted in actual harm because the nurse assessed him as having pain but failed to treat the residents pain with non pharmacological or pharmacological interventions both of which he had physician orders for. The nurse further failed to assess the pain for location or duration and never notified the physician or the residents increased pain. For Resident #104 the resident an increase in pain upon movement and transfers. Though the facility treated her pain and increased her pain medications they failed to assess the cause of the pain which was later identified at two (2) fractures. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure a dignified dining experience by providing plastic silverware to residents during meals and failed to announce/knock on the door before entering a resident's room. This failed policy had the potential to affect more than a limited number of resident's. Resident Identifier : #20. Facility census: 102.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a homelike dining environment by having soiled air conditioning vents in the main dining room area. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 102.

Inspectors wroteBased upon record review and staff interviews, the facility failed to ensure reported irregularities from the Pharmacist were reviewed and addressed by the Resident's physician. This was found to be true for three (3) of five residents reviewed during the annual survey process. Resident identifiers: #10, #12, and #85. Facility census: 102.a) Resident #10 The Long Term Care Pharmacist Recommendation completed in accordance with monthly Medication Record Review (MRR) dated 04/30/25, stated (First name of Resident) has orders for both Meloxicam tabs and Voltaren gel. Since these medications are both NSAIDs, and taking them together increases risk of side effects, please consider discontinuing one of these orders. This recommendation was not reviewed by the resident's medical provider and no action was taken on the recommendation. [...]

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to ensure menus were followed and distributed and residents received the foods they wanted/ordered. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #112. Facility Census:

Inspectors wroteBased on observations, staff interview and resident interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance and provide food that is palatable, attractive, and at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #35, #20, #112, and #115. Facility Census: 112. a) Resident #115 During an interview with Resident #115 on 08/11/25 at 12:17 pm he stated, the food was not good. He indicated it was always ice cold when he got it. He stated he never gets what supposed to be on the menu it is always different and not as good as what is on the menu. b) On 08/14/2025 at 12:55 PM, a test tray containing spaghetti with meat sauce, parmesan baked zucchini, garlic bread and ice cream, was provided to the state surveyors. [...]

Inspectors wroteBased on record review, observation, resident interview and staff interview, the facility failed to ensure meals were provided at regular times for the residents and failed to ensure a resident received breakfast and lunch on his dialysis days. This failed practice had the potential to affect more that a limited number of residents. Resident Identifier: #33. Facility Census: 102. b) Resident #33 During an interview with Resident #3 on 08/11/25 at 3:22 PM the resident stated, the facility does not consistently send him a lunch to dialysis he stated sometimes the aide will make him one but it is not very often. A review of Resident #33's medical record found a physician's order which read as follows: [...]

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 102Findings included: a) The facility's policy and procedure for Receiving and Storage of Food stated, Date the food packages and store them properly. when receiving items, Dry Foods - Store opened packages in closed, labeled containers. and Frozen Food - tightly wrap open bags and boxes to prevent freezer burn. The facility's policy and procedure for Storage of Resident Food included: Daily monitoring for refrigerated storage duration and discard of any food item that may have been stored for >7 days. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were maintained accurately in accordance with accepted professional standards for residents in the facility as evidenced by the following: [...]

Inspectors wroteBased on observation, record review, and staff the facility failed to establish and maintain an infection prevention and control program designed toprovide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Transmission based precautions were not followed for two (2) of three (3) residents reviewed for transmission based precautions. Proper hand hygiene was not performed for one (1) of two (2) dressing change observations. Resident Identifiers: #43 and #107. Facility census: 102.

Inspectors wroteBased on record review and staff interview, the facility failed to provide influenza and pneumococcal vaccines within accepted standards of practice. The facility failed to retain documentation that residents or their resident representatives received education regarding the vaccines and failed to retain documentation as to whether the vaccines were accepted or refused. These deficient practices had the potential to affect three (3) of five (5) residents reviewed for the care area of influenza and pneumococcal immunizations. Resident Identifiers: #20, #33, #107. Facility census: 102. Findings Included: [...]

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to ensure food preparation/food service areas and resident rooms were free from visible signs of insects. This failed practice had the potential to affect more than a limited number of residents: Resident identifiers: #26 and #112.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the continuing competence of nurse aides by not providing at least twelve (12) hours of continuing education per year. This was found to be true for three (3) of five (5) nurse aide training records reviewed during the annual survey process. Nurse Aide (NA) identifiers: #5, #10, and #77. Facility census: 102.

Inspectors wroteBased upon record review and staff interview, the facility failed to inform a resident's representative of the benefits and risks of psychotropic medication. This was found to be true for one (1) of five (5) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102a) Resident #6A review of the Resident's medical record, Section entitled Orders, documented the following psychotropic medications being given: Zyprexa Oral Tablet 15 MG (Olanzapine)Give 15 mg by mouth at bedtime for schizoaffective disorder04/03/25The Resident did not have capacity to make her own Informed consents, so the representative signed and acknowledged consent specifying the benefits and risks affiliated with the following medications on 12/04/24 for Lorazepam, Zoloft, Haloperidol. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to honor residents' rights to establish directives regarding end-of-life care. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advanced directives. Resident Identifier: #23. Facility census: 102.

Inspectors wroteBased on record review and staff interview, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one(1) of nine (9) residents sampled during the facility's annual survey review . This failed practice had the potential to affect a limited number of residents. Resident identifier: #110. Facility Census: 102.

Inspectors wroteBased upon record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) when a new diagnosis of a major mental disorder occurred. This was found to be true for one (1) of ten (10) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102. Findings Included:A) Resident #6The Resident's PASARR was completed on 11/07/24 by the facility. At that time the resident had the following diagnoses Bipolar Disorder, unspecified and Generalized Anxiety Disorder. Section V of the PASARR is Supplemental Questions. Question 40 is Major Mental Illness or suspected MI, with a list of options to check. Checked on this question was:#F for Schizoaffective Disorder and#H for Other. Other was specified to be Bipolar disorder, unspecified and Generalized Anxiety Disorder. A Level II evaluation was not required. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement Resident #33's care plan in regards to weights and Resident #85's care plan in regards to pain management. This was true for two (2) of 37 sampled residents reviewed during the long term care process. Resident Identifier: #33 and #85. Facility Census #102. Findings Include: a) Resident #33 A review of Resident 33's medical record on 08/11/25 found the following focus statement on the care plan: -- Resident with potential for altered nutrition status/nutrition related problems d/t diabetes obesity vitamin d deficiency, need for vitamin supplements, c/o heartburn w. nausea at times. He has the potential for weight fluctuations r/t kidney failur w/HD. Planned weight loss program r/t scheduled paracentesis. The goal associated with this practice statement read as follows: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise the comprehensive care plan when the resident's wishes for end-of-life treatment changed. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advance directives. Resident Identifier: #23. Facility census: 102.

Inspectors wroteBased upon record review and staff interview, the facility failed to ensure the Resident's environment remained as free of accident hazards as possible. This was found to be true for one (1) of seven (7) residents reviewed during the annual survey process. Resident identifier: #10. Facility census: 102.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #85 was provided with colostomy care in accordance with professional of care and to meet the needs of the resident. This was true for one (1) of one (1) residents reviewed for colostomy care during the long term care survey process. Resident Identifier: #85. Facility Census: 102. a) Resident #85 During an observation on the first day of the survey in the afternoon Resident #85 was observed leaving his room. Bowel movement was observed falling from the resident colostomy bag onto the floor. Resident #85 was assisted back to his room by a nurse at that time. A review of Resident #85's medical record found Resident #85 was admitted to the facility on [DATE]. Further review of the record found a hospital Discharge summary dated [DATE]. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store medications in accordance with professional standards of practice. A multi-use vial of insulin was not dated when first accessed. This was a random opportunity of discovery. Resident #107. Facility census: 102.

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician's orders for laboratory testing. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of behavior/emotional. Resident Identifier: #43. Facility census: 102.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure residents were served food prepared in a form designed to meet their individual needs. Resident identifier: #82. Facility census: 102.

Inspectors wroteBased upon record review and staff interviews, the facility failed to ensure residents were served food in accordance to their preferences and intolerances. This was found to be true for three (3) of thirteen (13) residents reviewed during the annual survey process. Resident identifiers: #10, #83, #7. Facility census: 102. a) Resident #83 On 08/11/2025 at 01:13 PM, Resident #83 did not receive his Frozen Nutritional Supplement as printed on the resident's tray card in bold print. Nurse Aide (NA) #58 confirmed the resident did not receive his supplement that date. NA #58 went to the kitchen and got the supplement for the resident following state surveyor intervention. b) Resident #7 On 08/11/2025 at 11:42 AM, during the initial resident interview, Resident #7 reported she was allergic to fish and had asked for the alternate sandwich. [...]

Inspectors wroteBased on observation, record review, and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, during a confirmed COVID 19 outbreak. This failure to protect the residents from the spread of COVID 19, resulted into an Immediate jeopardy with the potential to cause illness and/or death to the residents who reside in the facility. Facility census: 111.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to provide reasonable accommodation of resident needs and preferences for Resident #25. This is true for one (1) of one (1) residents reviewed during the survey process. Resident Identifier: #25. Facility Census:111.

Inspectors wroteBased on observation, resident interview, family interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #84 Facility census: 111.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for four (4) of four (4) Residents reviewed for the Activity Care Area. Resident Identifiers: Resident #69, #86, #66, and #35. Facility Census:111.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This deficient practice had the potential to affect more than an isolated number of residents residing in the building. Resident identifiers: #218, #96, #46, #101, #70, and #167. Facility census: 111.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. Unsanitary and unclean areas were discovered. The facility failed to store utensils and serve drinks in a sanitary manner. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the resident's refrigerator. Facility Census:111 Findings Included: A review of the facility policy titled: Storage of Resident Food with a effective date of 01/19/21 read as follows: Procedure: .II .E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe. F. Frozen foods must be stored and keep frozen III. [...]

Inspectors wroteBased on record review, and staff interview, the facility failed to inaccurate establish and maintain complete and accurate surveillance and line listing. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident identifiers: #67, #167, and #70. Facility census 111.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain equipment in safe operating conditions. The ice machine did not have a one-inch air gap for drainage. This failed practice had the potential to affect all residents currently receiving nutrition from the facility kitchen. Facility Census: 111.

Inspectors wroteBased on observation and staff interviews the facility failed to maintain an environment free from flies. This practice had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 111.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #70. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 111.

Inspectors wroteBased on Resident interview, staff interview and record review. The facility failed to honor the choices of the residents in the care area of showers and/or baths. This failed practice was true for one (1) out of three residents (3) reviewed for choices. Resident identifier: # 36. Facility census: 111.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN 9CMS-10055) to beneficiaries and/or beneficiary's representatives. This failed practice was true for one (1) of three (3) residents reviewed. Resident identifiers: Resident #318. Facility Census: 111.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Room C6 privacy curtain was soiled, and Resident #79's personal fan needed to be cleaned. Resident identifier: Resident #79. Facility Census:

Inspectors wroteBased on medical record review and staff interviews the facility failed to correctly code resident discharge in the Minimum Data Sets (MDS) for one (1) of three (3) sampled residents reviewed for closed records. Resident #115's MDS was inaccurate in discharge status. Resident identifier: #115. Facility census:

Inspectors wroteBased on resident interview, observation, record review, and staff interview. The facility failed to ensure resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Resident identifier: #218. Facility census 111.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of 24 residents in the long-term care survey sample. The facility failed to monitor Resident #96's blood pressure. Resident identifier: #96. Facility census: 111.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure the resident environment remains as free of accident hazards as is possible. This failed practice was a random opportunity for discovery, medication in residents' room. This had the potential to affect a limited number of residents that currently reside at the facility. Resident identified: #218. Facility census 111.

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents received catheter care at a professional standard of practice. This was a random opportunity for discovery, and had the potential to affect one resident. Resident identifier: #46. Facility census 111.

Inspectors wroteBased on Resident interview, observation, record review, and staff interview, the facility failed to provide colostomy care with the current professional standards of care. This was true for one (1) out of one (1) reviewed for colostomy care. Resident identifier: Resident #218. Facility census 111.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to provide necessary respiratory care and services. This is true for one (1) of one (1) residents reviewed for the respiratory care area. Resident #85 was not receiving his oxygen therapy at the prescribed rate. Resident identifier: #85. Facility Census:

Inspectors wroteBased on observation, staff interview and medical record review the facility failed to provide a two (2) handled spouted cup for a resident at meal time. This was a random opportunity for discovery. Resident identifier: Resident #101. Facility Census: 111.

Inspectors wrotec) Resident #168 Review of Resident #168's medical records showed an order written on 10/19/23 for lamotrigine (Lamictal), 25 milligrams (mg), orally, one (1) time a day for health maintenance. During an interview on 10/24/23 at 2:25 PM, the Director of Nursing (DON) was informed health maintenance was not an appropriate indication for this medication. During an interview on 10/25/23 at 3:41 PM, the DON stated Resident #168 was receiving lamotrigine for depression, and the order was revised to reflect this. Based on observation, record review, resident interview and staff interviews the facility failed to ensure accurate and complete identifying information on a medical record. This was true for three (3) of 24 in reviewed for the Long-Term Care Survey Process (LTCSP) and one (1) of three (3) reviewed for closed record. Resident identifiers: #101, #168 and #116. Facility Census: 111.

Inspectors wroteBased on Resident Council interview, observations and staff interview, the facility failed to display the most recent State inspection in a readily accessible area frequented by residents. It was discovered the State inspections were placed in an area too high for residents to reach. This had the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to provide Resident #74 with a dignified dining experience. Resident #74 was not served his meals in the traditional dinnerware that was provided to all other residents in the facility. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: Resident #74. Facility census: 82.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the resident's care plan when a change occurred. This deficient practice had the potential to affect one (1) of 20 residents reviewed during the long-term care survey process. Resident identifier: #39. Facility census: 82.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to ensure appropriate treatment and care for a urinary catheter drainage bag. This was discovered for one (1) of one (1) residents reviewed for the care area of urinary catheters during the Long Term Care Survey Process. The bedside urinary catheter drainage bag for Resident #18 was not positioned properly under her wheelchair, which allowed the catheter drainage bag to come in contact with the floor. Resident identifier: #18 Facility census:

Inspectors wroteBased on observation and staff interview the facility failed to ensure residents who require dialysis receive services, consistent with professional standards of practice. The facility failed to have a dialysis emergency kit available at bedside. This was discovered for one (1) of (1) one resident reviewed for the care area of dialysis during the Long Term Care Survey Process Resident Identifier # 50. Facility Census: 82 Findings Included: a) Resident # 50 On 04/12/22 at 9:10 AM, observations found no emergency equipment at Resident # 50's bedside who uses a Peracath for dialysis access. On 04/12/22 at 9:16 AM, Licensed Practical Nurse (LPN) # 101 confirmed Resident # 50 uses a Permacath for dialysis. LPN # 101 also confirmed no emergency kit was available at the bedside of Resident # 50. LPN #101 stated No, there are no clamps at bedside. [...]

Inspectors wroteBased on observation, staff interview and resident interview, the facility failed to serve food that was palatable and at a safe and appetizing temperature. The failed practice had the potential to affect a limited number of residents currently receiving nutrition from the facility's kitchen. Resident Identifier: Resident # 8. Facility Census: 82 Findings Included: A) Resident #8 During an interview 04/12/22 at 8:30 AM Resident #8 stated the food is always cold. On 04/12/22 at 12:06 PM, temperatures were obtained on the lunch meal tray for Resident #4 (Resident #4's tray was selected because it was the last tray to be served) at the time of service. The following temperatures were obtained by the Dietary Services Supervisor (DSS) #54 using his thermometer: --Brown Beans: 146 degrees Fahrenheit (F) --Green Beans: 123 degrees F --Ham with gravy: 113 degrees F --Diced Potatoes: [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a resident's care plan included a description of the care and services to be provided by hospice and the facility. This was discovered for one (1) of one (1) residents reviewed for the care area of hospice services during the Long Term Care Survey Process. The care plan for Resident #2 did not specify care and services to be provided by hospice or the facility. Resident identifier: #2 Facility census: