Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summit, The during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as evidenced by multiple residents reporting and being observed with live bedbugs and bites, ongoing infestations in several rooms, and inconsistent application of pest control measures such as spraying and heat treatment. Staff interviews revealed that not all rooms were routinely inspected, professional exterminators had not been used for bedbugs in over a year, and clutter and resident refusal further hindered effective treatment.
Missing CNA Annual Training and Competency Documentation: The facility failed to provide documentation showing CNAs completed the required annual 12 hours of in-service training and competency skill check offs. The DON said monthly in-services were provided, including hand hygiene, but could not produce written records, and no current employee training or competency documentation was available. A CNA and a CMT reported recent in-services, but neither knew where the documentation was kept.
Surveyors observed widespread kitchen sanitation and food safety failures, including dust, grime, debris, and food residue on fans, drains, floors, the stove, refrigerators, and prep surfaces. They also found unlabeled and undated food, uncovered items in a freezer, no dish machine test strips available, sanitizer not being tested, towels not stored in sanitizer, and multiple staff members handling food and kitchen items without proper handwashing or glove changes.
Failure to document QAPI activities was identified after record review and interview. The facility had no documented QAPI plan since the last survey or within the past year, even though the QA committee reviewed prior citations, weekly reports on falls, wounds, weight loss, antibiotic and antipsychotic use, infections, behavior incidents, and resident council reports. The Administrator stated the committee met at least quarterly, but QAPI/PIP action plans, monitoring, and resolved items were only reported verbally and were not documented.
The facility failed to maintain an ongoing IPCP with written infection surveillance tracking and monthly QA reporting for most of the review period, and the DON stated infection surveillance and trending had not been documented since the prior ICP left. The facility also failed to ensure proper hand hygiene during incontinence care for a resident with cerebral palsy and dementia, as staff did not sanitize or wash hands between glove changes or when moving from dirty to clean tasks, and one CNA applied barrier cream and continued care with soiled gloves.
No certified ICP was employed to coordinate the infection prevention and control program. The facility’s policy identified the ICP as responsible for surveillance, data analysis, documentation, and communicable disease reporting, but review showed no current employee with ICP certification. The DON was completing infection control surveillance without ICP certification, an LPN was in training but had not passed the final exam, and the DON stated the last ICP had left the facility the prior year.
A drainpipe from the Victory Refrigerator was observed not reaching the nearby drain and instead dripping water onto the floor beside a bolt, causing rust before the water and rust ran into the drain. The Dietary Manager said the drainpipe had been out of place for about a month and was unsure what happened to it or whether it was scheduled for repair.
Dusty Laundry Fan: Surveyors observed a fan in the laundry area with a heavy buildup of dust on the blades and grate, and it was directed toward clean clothes on a hanger. An LA and the Housekeeping/Laundry Supervisor both stated they did not know when the fan was last cleaned.
Lack of negative air flow was found in required areas, including biohazard rooms and resident room restrooms. Surveyors observed no negative air flow in the first-floor biohazard room, two resident room restrooms, and the second-floor biohazard room. Maintenance staff said they did not know how long the condition had existed, and Corporate Maintenance reported the motor for the negative airflow system was broken.
A facility failed to complete a closed record by not including a recapitulation of stay for a discharged resident with multiple complex diagnoses, including anemia, PTSD, anxiety, HTN, alcohol dependence, diabetes, and bilateral lower-extremity amputations. The resident was discharged to a sibling’s home with medication instructions, but the medical record lacked the required recapitulation; the SS designee did not know what it was, and the DON stated it should have been completed by the charge nurse.
Failure to provide needed perineal care and repositioning: A cognitively impaired, fully dependent resident on hospice with bowel and urine incontinence was supposed to be checked every 2 hours, but observations showed staff did not perform peri care checks or reposition the resident during extended periods. The care sheet documented peri care for the day without a time, while CNA and LPN interviews confirmed the resident should have been checked routinely.
A resident with dementia, anxiety, weakness, RA, incontinence, and wheelchair dependence did not have an individualized activity plan that was goal directed or based on identified preferences and abilities. The MDS did not identify activity preferences, the care plan goal did not specify how many times per week participation was expected, and the one-to-one log showed only weekly nail care with no other documented activities. Observations showed the resident often had nothing available to do before scheduled activities began, while staff described the resident as repetitive and noted preferences such as church, bingo, parties, snacks, personal care, and being involved with what was going on.
A resident with ESRD and a left leg fracture was ordered to receive a bone stimulator to the left lower extremity for 20 minutes daily, but the resident was observed using the device independently in the room. The chart did not show an assessment of the resident’s ability to self-administer the device, and the care plan did not include details about the stimulator or how it was to be administered. Staff interviews showed the resident was not authorized to operate the device independently and that nursing staff were supposed to place and remove it.
A resident with schizophrenia was observed storing used cigarette butts in a cup and using the paper from discarded cigarettes to roll tobacco, with no secure storage container provided for smoking materials. Another resident with multiple chronic conditions was found asleep in the smoking room holding a lit cigarette, with a hole noted in clothing near the cigarette. The record showed no post-incident smoking re-assessment, no additional monitoring documentation, and no care plan update reflecting the change in smoking safety status.
A resident with a colostomy was assessed as fully capable of independent pouch emptying, changing, and skin care, and the resident stated self-care was done without staff help. Staff and the DON confirmed the resident performed colostomy care independently, but the POS only included an order to check the stoma and surrounding skin daily and did not include a physician's order for self-administration and care. The resident's care plan and assessments reflected colostomy self-care, yet the required order was not documented on the POS.
A resident with heart disease, depression, alcohol abuse, pain, and a colostomy experienced gradual weight loss and poor intake, but the RD, nursing, and physician documentation did not show a thorough re-assessment of chewing/swallowing ability, diet texture, food preferences, or nutritional interventions. The resident continued to refuse supplements, meal intake records were incomplete, Prosource was not consistently given as ordered, and observations found cold, uneaten meals in the resident’s room while staff confirmed no swallow study had been completed and the diet remained regular.
Failure to follow dialysis access monitoring orders: A resident with ESRD and a left arm shunt had physician orders for every-shift thrill/bruit checks and daily access-site assessments, but the TAR showed multiple missed and incomplete entries with no documented rationale. The resident said staff did not check the shunt before dialysis because he/she left early, and an LPN and the DON acknowledged the documentation did not reflect the ordered monitoring.
Medication refrigerators were not properly monitored or maintained. In the second floor med room, the refrigerator temperature was 34 degrees, the unit had a sticky purplish substance on the door and inside, and the temperature log had multiple missing entries. The refrigerator stored unopened insulin and an emergency insulin kit, while staff stated night shift was responsible for checking temperatures, documenting them, and cleaning the refrigerator.
A resident with cerebral palsy and peripheral vascular disease did not consistently receive or have documented wound care treatments and skin assessments as ordered. Multiple missed or undocumented treatments were identified in the TAR, and weekly skin assessments were not completed as scheduled. Staff interviews revealed that treatments may have been performed but not documented, with workload cited as a barrier, and the DON confirmed expectations for proper documentation and completion of care.
Two residents with pressure ulcers or at risk for skin breakdown did not receive consistent wound care treatments, weekly wound measurements, or full body skin assessments as required by facility policy. Documentation was incomplete or missing for multiple treatments and assessments, and one resident lacked a care plan focus for skin impairment. Staff interviews revealed confusion over responsibilities and cited workload as a barrier to proper documentation.
The facility did not complete thorough fall investigations or root-cause analyses for three residents who experienced falls, as required by policy. Incident reports and medical records were missing critical details, care plans were not updated after falls, and staff interviews confirmed inconsistent documentation and follow-through. The DON acknowledged that RCAs were not documented and that incident reports lacked necessary information.
Failure to Maintain Effective Bedbug Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in live bedbugs being observed in the rooms of six sampled residents out of fifteen. Multiple residents reported seeing live bedbugs in their rooms, experiencing bites, and finding bedbugs on their bodies and belongings. Observations confirmed the presence of live and dead bedbugs in resident rooms and bathrooms, as well as visible bites on several residents. Some rooms were noted to be cluttered, which complicated treatment efforts, and residents reported ongoing issues despite previous treatments. Interviews with residents revealed that some had been bitten by bedbugs, while others had not noticed bites but had seen live bugs in their rooms. Several residents stated that their rooms had been sprayed or treated, but the infestation persisted. Staff interviews indicated that pest control measures were inconsistently applied, with reliance on in-house spraying and heat treatment machines. The facility had not engaged a professional exterminator for bedbugs in over a year, and routine inspections of all rooms were not conducted. Staff also reported challenges in treating rooms due to resident refusal of certain treatments and difficulties in managing clutter. Facility leadership acknowledged ongoing bedbug issues, attributing some of the challenges to new admissions from high-risk populations and a recent change in maintenance personnel. The facility's pest control policy outlined comprehensive steps for managing bedbug infestations, but interviews and observations indicated that these procedures were not consistently followed. The lack of regular inspections, incomplete treatment of affected and adjacent rooms, and inconsistent communication and documentation contributed to the continued presence of bedbugs and resident exposure.
Missing CNA Annual Training and Competency Documentation
Penalty
Summary
The facility failed to provide the required annual 12 hours of in-service training and competency skill check offs for CNAs. Review of the CNA Continuing Education Policy dated 5/25/23 showed that all CNAs must complete a minimum of 12 hours of continuing education annually, the DON is to create an annual training schedule and ensure relevant topics are covered, CNAs must submit proof of completed training to HR, and the supervisor is to review training records quarterly and maintain compliance records in personnel files. Review of the undated Facility Assessment showed administration did not have information regarding how staff training would be completed. During interviews, a CNA and a CMT reported that the facility had recently offered in-services related to hand hygiene and that monthly in-services were normally held on pay days, but they were not aware of where the in-services were documented. The DON stated the facility provided monthly in-services but could not provide written documentation of those trainings, had not completed nursing staff and CNA skills check offs or competencies, and did not have documentation showing current employees had the required annual training hours. The Administrator stated he/she would expect documentation showing the CNA 12-hour training and skills check offs/competencies were completed, but none was provided. Review of requested CNA and nursing staff in-service and skills check off records showed no documentation was provided to show current employees had the required training hours and competencies.
Kitchen Sanitation, Food Storage, and Hand Hygiene Failures
Penalty
Summary
The facility also failed to maintain food labeling, sanitizer use, and hand hygiene. Surveyors observed opened and cut food items in the refrigerator with no dates, a baggie of red sauce with no label or date, and food in Freezer #1 that was not covered or contained. Staff did not have sanitizer test strips available for the dish machine, and sanitizer strips presented by the Dietary Manager were rolled and unlabeled. Staff used a towel to wipe preparation tables but did not store it in the sanitizer bucket when not in use, and sanitizer solution was not tested. Multiple staff members were observed handling food and kitchen items without washing hands before putting on gloves, after handling trash, or after leaving and returning to the kitchen. The Dietary Manager stated staff should wash hands every time they come into the kitchen, every time they touch something different, and before putting on gloves, and that sanitizer should be checked every two hours, but these practices were not followed during the observations.
Failure to Document QAPI Activities and Performance Monitoring
Penalty
Summary
Failure to ensure QAPI activities were documented was identified after interview and record review. The facility did not submit documentation of a completed QAPI plan since the last survey or within the last year, despite the facility assessment stating that the QAPI team and operational director were responsible for annually obtaining, reviewing, and revising facility profile information, extracting MDS data, reviewing census and condition data, and extracting CASPER reports to review quality measures. Review of CASPER reports dated 7/21/25 showed repeat deficiencies cited since July 2022 in resident rights, resident care, rehabilitation services, staffing, infection control, dietary services, and life safety code. The Payroll Based Journal report showed low weekend staffing in two quarters and a one-star rating in one quarter. During interview, the Administrator stated the QA Committee included the Administrator, Corporate Manager, Medical Director, Social Services Director, Dietary Manager, DON, Maintenance Director, and sometimes the Activity Director. The Administrator said the committee met at least quarterly and reviewed prior citations and weekly reports on falls, wounds, weight loss, antibiotic and antipsychotic medication use, infections, behavior incidents, and resident council reports to determine areas for improvement. The Administrator also stated that the facility had not been documenting any QAPI plan of action, PIP, monitoring of action plans, or QA areas completed through QAPI, and that results were reported verbally in QA Committee meetings without documentation of prior or current action plans, monitoring, or resolved QAPI items.
Infection Control Surveillance and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an ongoing infection prevention and control program with surveillance, tracking, and trending of infections. Review of the facility’s infection control surveillance log showed the Director of Nursing did not have written infection surveillance tracking from January 2024 through May 2025, and monthly infection control reports were not documented for review by the Quality Assurance Committee. The DON stated he/she was responsible for completing the infection surveillance documentation, but had not been documenting ongoing monthly infection surveillance tracking and trending since the prior Infection Control Preventionist left in June 2024. The Administrator stated the DON was completing the surveillance even though he/she was not ICP certified, and the facility did not have documented outcomes from infection control review by the QA team. The facility’s infection control program, hand washing policy, and gloving policy required surveillance, documentation, and proper hand hygiene during resident care. However, the DON reported that infection prevention interventions and education related to infection trends were not documented, and antibiotic stewardship documentation was also not being completed. The facility assessment identified infection prevention as part of general nursing-related infection prevention, including identification and containment of infection, but the required surveillance process was not maintained in writing for most of the 18-month review period. The facility also failed to ensure proper hand hygiene during personal care for one resident who had cerebral palsy and dementia and required assistance with bathing, personal care, and incontinence care. During observed incontinence care, the resident was in bed with urine odor present, and staff provided perineal care while changing gloves between some tasks but did not sanitize or wash hands between glove changes or when moving from dirty to clean tasks. One CNA applied barrier cream using gloved hands and continued care with the same soiled gloves, while another CNA did not perform hand hygiene before donning gloves. Staff interviews confirmed that hand hygiene should have been performed before resident care, between glove changes, and when moving from dirty to clean processes.
No Certified Infection Preventionist Assigned
Penalty
Summary
The facility failed to employ a certified Infection Control Preventionist (ICP) at least part time to coordinate the infection prevention and control program. The facility’s General Infection Control Program Policy identified the ICP as the person designated to serve as coordinator of the infection prevention and control program and to oversee surveillance, data analysis, documentation, and communicable disease reporting. However, review of the requested ICP certification showed the facility did not have a current employee with a certificate of completion as an ICP. The Director of Nursing (DON) and an LPN who was in training for the ICP position did not have active ICP certification. During interview, the Administrator stated that the DON was currently completing infection control surveillance even though the DON was not ICP certified, and that the DON had not been tracking and trending infections until the prior month. The Administrator also stated the facility planned to have a prior infection preventionist return, and that the LPN in training had started the prior month but had not passed the final ICP exam. The DON confirmed the facility did not employ a certified ICP, stated the last ICP left in June 2024, and acknowledged the DON had not completed the ICP program and was not ICP certified.
Refrigerator Drainpipe Not Properly Draining
Penalty
Summary
The facility failed to repair a drainpipe connected to the Victory Refrigerator that was not draining into the adjacent drain. During observation, the drainpipe was seen coming off the refrigerator and dripping water onto the floor next to a bolt, causing the bolt to rust, with the rust and water then running onto the floor and into the drain. During interview, the Dietary Manager stated the drainpipe had not reached the drain for about a month, did not know what happened to it, and thought it was on the schedule to be fixed but was not sure.
Dusty Laundry Fan
Penalty
Summary
The facility failed to ensure the fan in the laundry area was free from a heavy buildup of dust. During observation on 7/28/25 at 1:41 P.M., surveyors saw one fan with heavy dust buildup on the blades and grate, and the fan was directed toward clean clothes on a hanger behind Laundry Aide A. During interview on 7/28/25 at 1:42 P.M., Laundry Aide A stated he/she did not know the last time the fan was cleaned. During interview on 7/28/25 at 1:49 P.M., the Housekeeping/Laundry Supervisor stated he/she brought the fan out of a closet and did not know the last time it was cleaned.
Lack of Negative Air Flow in Biohazard Rooms and Resident Restrooms
Penalty
Summary
The facility failed to ensure negative air flow was present in required areas, including the soiled utility/biohazard rooms, shower rooms, and resident room restrooms. During observation with Maintenance Person A, surveyors found no negative air flow in the biohazard room behind the first floor nurse's station, in the restroom of one resident room, in the restroom of another resident room, and in the second floor biohazard room. During interview, Maintenance Person A stated he/she did not know how long negative air flow had been absent, and the Corporate Maintenance Person said the motor operating the negative airflow in the first floor biohazard room and rooms throughout the facility was broken. The deficiency affected all residents because none of the resident room restrooms had negative air flow, and the facility census was 56 residents.
Incomplete Closed Record for Discharged Resident
Penalty
Summary
The facility failed to ensure a closed record was complete by not including a recapitulation of stay for one sampled closed-record resident. Resident #62 was admitted with multiple diagnoses, including congenital dyserythropoietic anemia, PTSD, anxiety disorder, essential hypertension, alcohol dependence, absence of the right leg above the knee, anemia, absence of the left leg below the knee, homelessness, type 2 diabetes mellitus, low back pain, other chronic pain, sleep disorder, and dependence on a wheelchair. The resident’s quarterly MDS dated 5/9/25 showed the resident was cognitively intact and had medically complex conditions. Nursing notes showed the resident was discharged by facility van to his/her siblings’ house, and discharge instructions included a list of medications. Review of the medical record showed that on 6/2/25 there was no recapitulation of stay. During interview, the Social Services Designee stated he/she did not know what a recapitulation was and did not have a list of items the resident brought to the facility. The DON stated there should have been a recapitulation and that the charge nurse was responsible for it.
Failure to Provide Needed Perineal Care and Repositioning
Penalty
Summary
The facility failed to ensure perineal care was provided as needed for one resident who was cognitively impaired, always incontinent, dependent on staff, and receiving hospice services for terminal illness. The resident’s admission record listed dementia, type 2 diabetes mellitus, essential hypertension, and hyperlipidemia. The care plan identified the resident as totally dependent on staff, requiring a Hoyer lift for transfers, with impaired thought process and communication related to severe dementia. The facility policy stated that bed mobility care is performed daily every 2 hours for limited mobility residents and every 4-6 hours depending on tissue tolerance and whenever needed. The resident’s nursing care sheet for July 2025 documented that peri care was done for the day, but it did not list the time the care was provided. Hospice notes documented bowel incontinence, urine incontinence, inability to change position, and that incontinence was being managed by briefs and proper skin care. During interviews, CNA B, LPN A, CNA A, and the DON stated that the resident should be checked every two hours. However, observations on 7/30/25 and 8/1/25 showed staff did not perform peri care checks or reposition the resident during the observed periods, and the resident remained in the same position while lunch was served.
Individualized activity plan was not goal directed or based on resident preferences
Penalty
Summary
The facility failed to ensure an individualized activity plan was goal directed and incorporated the interests and abilities of one resident with unspecified dementia, anxiety disorder, muscle weakness, rheumatoid arthritis, urinary incontinence, other malaise, and wheelchair dependence. The resident’s quarterly MDS showed modified independence in some new situations, setup or clean-up assistance with eating and dental care, partial to moderate assistance with transferring, dressing, and toileting, and substantial to maximal assistance with bathing. The MDS also noted that the resident’s activity preferences were not identified. The resident’s care plan stated the resident had limited to no activity involvement and was receiving one-to-one activities, with a goal that the resident would participate in activities of choice times per week by the review date. However, the goal did not specify how many times per week participation was expected. Interventions listed one-to-one activities and preferences such as socializing, nail care, and watching specific TV channels, along with staff prompting and advance notification of activities. The Special Programming One to One Log showed only one-to-one nail care once per week, with entries for each Monday in July, and no other documentation showing the resident was offered or participated in other one-to-one or scheduled activities. Observations showed the resident sitting in the TV community area repeating requests to staff, including asking them to close cupboard doors and to get another resident, and later being in bed with no scheduled activities available after 2:00 P.M. on weekdays. On another morning, the resident was eating breakfast in the community TV area while no activities were occurring and nothing was available before scheduled activities began at 10:00 A.M. Staff interviews described the resident as repetitive, demanding, authoritative, and a retired nurse who responded to redirection through references to nursing experience, church, parties, bingo, snacks, personal care, and being involved with what was going on. The Activity Director stated the resident had one-to-one activities every Monday when doing nails but had not started measuring goals for this resident and did not know why the resident needed one-to-ones beyond not doing many other activities.
Failure to Follow Orders for Bone Stimulator Use
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with end stage renal disease, a left leg fracture, depression, anxiety disorder, high cholesterol, low iron, and dependence on dialysis. The resident’s quarterly MDS showed the resident was alert and oriented, independent or needing supervision with basic activities, and used a wheelchair for mobility. The care plan did not show the resident’s current ambulatory status, any health concerns with the legs, or details about the bone stimulator, including what it was used for, how it was to be administered, who was to administer it, or how staff were monitoring its use. The physician’s orders included a bone stimulator to the left lower extremity for 20 minutes daily and checks of the left lower extremity every shift for integrity. The orders did not show that the resident was to self-administer the device. The TAR showed nursing staff documented administration on most days, but there were missed entries on several dates without documentation or rationale. The medical record did not show any assessment of the resident’s ability to apply and administer the bone stimulator device. During observation, the resident was seen using the bone stimulator independently in the room, with the device strapped to the lower leg and connected to a timer. When the timer ended, the resident removed the device and put it away, stating the resident used it independently and staff did not assess or monitor its use. CNA staff reported seeing the resident use the device but had never administered it and had not been told to do so. An LPN stated the resident was not authorized to operate the device independently and that nursing staff were supposed to place it on the resident, set the timer, and remove it when treatment was completed. The DON also stated the resident was not authorized to operate the bone stimulator independently and should not remove it.
Unsafe smoking materials storage and failure to reassess smoking safety after resident fell asleep with lit cigarette
Penalty
Summary
The facility failed to ensure resident smoking materials were stored safely for a resident with schizophrenia and tobacco use. The resident’s admission smoking agreement stated the resident would comply with the smoking policy, and an annual smoking safety screen had indicated the resident was safe to smoke without supervision. However, observation of the resident’s room showed a Styrofoam cup full of used cigarette butts with no storage container for smoking material. The resident was later observed collecting old cigarette butts, opening them to remove the filter, and emptying the tobacco onto newspaper to make cigarettes. The resident stated the old cigarette butt paper was being used to roll tobacco because new rolling papers were not available, and staff interviews reflected awareness that some residents collected used cigarette butts, while staff were not aware this resident was removing the filter and using the paper to roll tobacco. The facility also failed to ensure a safe smoking environment after a resident was found asleep while holding a lit cigarette. The resident had diagnoses including heart disease, hypertension, depression, anxiety, diabetes, and back pain, and was documented as alert, oriented, and able to smoke independently without supervision on the smoking safety assessment. Nursing notes showed staff found the resident in the designated smoking room with the head down, asleep while holding a lit cigarette in the hand resting on clothing, and a hole was noted in the clothing near where the cigarette had been held. Staff woke the resident, told the resident not to sleep in the smoke room with a lit cigarette, and the resident exited after putting out the cigarette. After this incident, there was no smoking re-assessment completed, no documentation of additional monitoring, and no update to the care plan reflecting the change in the resident’s smoking safety status. The resident’s prior smoking assessment did not address whether the resident fell asleep while smoking, was easily distracted, or required return demonstration, and the care plan continued to reflect independent smoking without documenting interventions related to the incident. Interviews with staff and the DON confirmed that the resident had been found asleep with a lit cigarette, that the expectation was to reassess smoking safety and update the care plan, and that these actions were not documented in the record.
Missing physician order for colostomy self-care
Penalty
Summary
The facility failed to ensure physician's orders for self-administration and care of a colostomy were obtained and documented on the Physician's Order Sheet for one resident with a colostomy. The resident was admitted with diagnoses including heart disease, pain, depression, alcohol abuse, and colostomy. The facility's ostomy-colostomy policy stated that a resident who is able to perform self-care would be provided information and education on colostomy care, but it did not include a procedure or documentation method for physician's orders related to self-care. The resident's record showed a telephone order to check the stoma and surrounding skin daily for skin issues, redness, moisture, or mucous, but no physician's order for self-care and administration of the colostomy appeared on the POS in May, June, or July 2025. The resident's assessment for self-care of colostomy showed the resident understood the reason for the colostomy, was fully capable of infection control, could empty and change the pouch and clean the skin, and successfully completed return demonstration. The quarterly MDS showed the resident was alert and oriented, had no cognitive incapacity, and used a colostomy. During observation, the resident was seen with a clean colostomy bag on the dresser and stated that he/she had had a colostomy for at least two years and changed and cared for it independently without staff assistance. Staff interviews confirmed the resident could and did perform colostomy care, that nursing staff checked the stoma site daily and documented monitoring on the TAR, and that there should have been a physician's order for self-care and it should have been on the care plan. The DON also stated the resident had been performing self-care independently and that a physician's order for self-administration and care should have been on the POS but had fallen off.
Failure to assess and care plan ongoing weight loss and poor intake
Penalty
Summary
The facility failed to thoroughly assess a resident’s chewing and swallowing ability, failed to re-assess dietary needs and preferences in response to ongoing weight loss and poor intake, and failed to care plan nutritional interventions for a resident with gradual weight loss. The resident had diagnoses including heart disease, depression, alcohol abuse, pain, and a colostomy. The resident’s annual RD assessment noted a regular diet, independent eating, broken teeth, stable weight with health shakes, and refusal of supplements, but later documentation showed continued weight loss and no additional nutritional evaluation addressing preferences, swallowing, or chewing status. The resident’s weight declined over time, with monthly weights showing a drop from 128.5 pounds to 125.5 pounds and then to 120 pounds, while the record also showed continued refusal of supplements and no documented re-evaluation of diet texture or food preferences. Quarterly dietary notes did not document the resident’s weight status, eating habits, preferences, or nutritional interventions during the quarter, and the physician’s notes did not address the resident’s nutritional status or weight changes. Nursing documented weight loss and notified the physician, but there was no documentation of a RD referral at that time, and the medical record did not show a swallow study or other evaluation for chewing or swallowing difficulty. Later notes showed the resident continued to lose weight and had difficulty eating, with low lab values including potassium, sodium, calcium, and albumin. The physician ordered weekly weights, hydration, nutrition support, and Prosource, but the MAR showed Prosource was not administered as ordered on multiple occasions and meal intake documentation was incomplete, with many meals left blank and several recorded as zero percent eaten. Observations found cold, uneaten plates in the resident’s room along with snacks and food items, and the resident stated the food could be better and that he or she did not always like what was served. Staff interviews confirmed the resident had been taking meals to the room, not eating them, had not had a swallow study, and that the resident’s diet had remained regular without documented re-evaluation for softer foods or other nutritional changes.
Failure to Follow Dialysis Access Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for monitoring and documenting one resident’s dialysis access site. The resident had end stage renal disease, dependence on dialysis, a left upper extremity access shunt, and was alert and oriented with no cognitive incapacity. The facility’s dialysis policy required staff to palpate for thrill, auscultate for bruit, check distal pulses and circulation, assess for numbness, tingling, altered sensation, coldness, blisters, infection, warmth, tenderness, and open sores, and document assessment findings and interventions. Review of the resident’s physician orders and TAR for July 2025 showed orders to check the left upper extremity access shunt for thrill and bruit every shift and to assess the shunt area daily for blisters, distal pulses, tingling, numbness, infection, warmth, tenderness, and open sores. The TAR showed the daily shunt-area assessment was left blank on 7/11/25, 7/20/25, and 7/30/25 with no rationale documented. The order to assess for thrill and bruit every shift was not completed at all on 7/11/25 and 7/29/25, was completed only twice daily on multiple dates, and was completed as ordered on only part of the month. There was no documented rationale for the missed assessments. During interview, the resident stated staff did not check the dialysis shunt before leaving for dialysis because the resident left before 5:00 A.M., but staff did assess the shunt after return from dialysis. An LPN stated the nurse was supposed to check and document thrill and bruit every shift and assess for redness, bleeding, and bruising on the TAR, and acknowledged the TAR did not show documentation according to the physician’s orders. The DON stated the physician’s order should be followed as written until changed and expected nurses to check thrill and bruit daily on every shift and document the access site on the TAR.
Medication Refrigerator Temperatures Not Documented and Refrigerator Not Kept Clean
Penalty
Summary
Medication refrigerators in the facility were not maintained in accordance with the facility’s storage policy. During observation of the second floor medication room, the refrigerator temperature was 34 degrees, the side door and inside of the refrigerator had a sticky purplish substance, and the temperature log for July 2025 had 10 missing temperature entries out of 30 opportunities. The refrigerator also contained unopened diabetic insulin and a house stock emergency kit of insulin. Interviews with staff identified that night nursing staff were responsible for checking and documenting medication refrigerator temperatures nightly and cleaning the medication refrigerators as needed or as scheduled. The CMT, LPN, and DON each stated that night shift staff were responsible for these tasks, and the DON stated he/she was responsible for oversight to ensure safe medication storage in the refrigerator and cleanliness of the medication refrigerator.
Failure to Complete and Document Wound Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments and skin assessments were completed and documented as ordered for one resident with a history of cerebral palsy and peripheral vascular disease. The resident had multiple physician orders for wound care, including the application of protective gels and ointments to various areas on the lower extremities and feet. Review of the Treatment Administration Record (TAR) revealed numerous instances where treatments were either missed or lacked documentation across different shifts throughout March and April. Additionally, weekly skin assessments were not consistently completed, with a gap noted between 4/10/25 and 4/21/25. Interviews with nursing staff and the Director of Nursing (DON) confirmed that while treatments may have been performed, they were not always documented as required. Staff cited workload and time constraints as reasons for incomplete documentation, and there was uncertainty regarding whether treatments were consistently administered. The DON acknowledged responsibility for ensuring completion and documentation of both treatments and skin assessments, and staff were expected to follow established schedules and policies for wound care and assessment. The resident involved was cognitively intact and had a care plan addressing limited mobility and chronic wounds, including the use of protective boots and regular monitoring for skin issues. Despite these interventions, the facility did not adhere to its own policies for wound assessment and treatment documentation, resulting in missed or undocumented care for the resident's chronic wounds and skin conditions.
Failure to Complete and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments were completed and properly documented, including weekly wound tracking and measuring, for a resident with multiple pressure ulcers. Specifically, one resident admitted with diagnoses including dementia, diabetes mellitus, and hypertension, was under hospice care and had several pressure ulcers at various stages. The facility's records showed missed or undocumented wound care treatments over several shifts, and only one instance of wound measurement was documented by facility staff, despite policy requiring weekly assessments and documentation. Interviews with staff revealed confusion over responsibilities between hospice and facility staff, and a lack of consistent documentation of wound care and measurements. Another resident, admitted with diabetes, fibromyalgia, rheumatoid arthritis, and a history of toe amputation, was at risk for developing pressure ulcers and had a Stage III pressure ulcer upon admission. The facility failed to complete and document weekly skin assessments for this resident, with a gap in full body skin assessments noted in the records. Additionally, this resident did not have a care plan focus for skin impairment, contrary to facility policy and staff expectations. Interviews with nursing staff and the DON confirmed that wound care and skin assessments were expected to be completed and documented according to policy, but these actions were not consistently carried out. Staff cited workload and time constraints as reasons for missed documentation, and there was uncertainty about whether treatments were being performed or simply not recorded. The DON acknowledged the lack of daily wound documentation and incomplete care planning for the resident at risk, as well as the need for both hospice and facility staff to be involved in wound measurement and documentation.
Incomplete Fall Investigations and Lack of Root-Cause Analysis
Penalty
Summary
The facility failed to ensure that fall investigations were complete and thorough, including the completion of root-cause analysis (RCA), for three out of five sampled residents. The facility's own policies required licensed nurses to perform timely assessments, complete detailed fall investigation forms, and document all relevant information in the resident's clinical record after each fall. However, for the residents reviewed, incident/accident reports and medical records were missing critical information such as nurse notes, progress notes, and detailed descriptions of the falls. In several cases, the investigation forms lacked explanations of behavioral concerns, contributing diagnoses, and did not include RCAs. One resident with fibromyalgia and restless leg syndrome experienced two non-injury falls, but the investigation forms did not provide sufficient detail, and no RCA was completed. Additionally, a required positioning bar intervention was not in place during observation, and there was no documentation in the resident's chart related to the falls. Another resident, identified as being at risk for falls due to gait and balance problems, had a fall that was not reflected in the care plan, and the incident report lacked a detailed behavioral assessment and RCA. Similarly, a third resident with Parkinsonism and ataxic gait had a fall that was not documented in the care plan, and the incident report did not include an RCA or a nurse note in the chart. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the completion of fall investigations, documentation, and care plan updates. Staff acknowledged that incident reports were often incomplete, RCAs were not documented, and care plans were not consistently updated after falls. The DON confirmed that there was no specific place on the incident report to document the RCA and that RCAs were shared verbally rather than documented. These actions and omissions resulted in the facility's failure to maintain thorough and complete fall investigations as required by policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 813 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clara Manor Nursing Home | 0.6 mi | ★★★★★ | 21 | 1 |
| Bishop Spencer Place, Inc, The | 0.8 mi | ★★★★★ | 18 | 0 |
| Ignite Medical Resort Rainbow Boulevard, Llc | 1.8 mi | — | 0 | 0 |
| Parkway Health Care Center | 2.3 mi | ★★★★★ | 2 | 1 |
| Myers Nursing & Convalescent Center | 3.1 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Summit, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.