Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summit Ridge Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
Cold Main Dining Room Temperature: The facility failed to maintain comfortable and safe temperatures in the main dining room, which was repeatedly reported by residents as cold during meals. Observations found residents using coats and blankets in the dining room, and measured temperatures were below the facility’s 71 to 81 degree range, including readings of 68.6 degrees, 66.8 degrees, and an air vent blowing 46-degree air into the room.
A cognitively intact but non-ambulatory resident, dependent on staff for ADLs and incontinence care after an above-the-knee amputation, experienced significant delays in receiving needed incontinence care. The resident reported routinely waiting extended periods, including about 45 minutes on one observed occasion, after using the call light and requesting assistance from staff. When CNAs eventually provided care using a mechanical lift, the resident’s brief, gown, bedding, and mattress were found to be wet. This occurred despite a care plan and incontinence policy requiring incontinence care after each episode and timely response to call lights.
Two residents with severe cognitive impairment experienced physical abuse from another resident, resulting in visible injuries. In one case, a resident was grabbed by the arm during a meal, and in another, a resident was slapped in their room. Both incidents were confirmed by staff observations and facility investigations, indicating a failure to prevent resident-to-resident abuse.
A resident who required assistance with bathing due to physical limitations was not provided or offered scheduled showers for multiple extended periods, despite facility policy and a care plan indicating the need for regular hygiene support. Documentation was lacking for these missed showers, and both the resident and their representative reported lapses in bathing care.
The facility failed to ensure two residents received their $50 personal needs allowance, as SSA payments were used to pay the facility, leaving no balance for personal use. The former administrator confirmed that personal funds were used to pay down debts owed to the facility.
A resident with memory issues was struck by another resident in the dining area, while staff were unaware due to their backs being turned. The aggressor had a history of aggression, yet was unsupervised, leading to the incident. Surveillance confirmed the attack was unprovoked.
The facility did not adhere to its policy for timely reporting of suspected abuse, neglect, or theft. Two resident-to-resident altercations were reported to facility administration promptly but were not reported to the state survey agency within the required timeframe. Interviews with the former and current administrators and the social service director confirmed the delay in reporting.
The facility failed to provide necessary behavioral health care to residents with dementia, resulting in harm to a resident who exhibited aggressive behaviors and another who expressed suicidal ideations. Despite orders for psychological evaluations and care plans, there was a lack of effective interventions and documentation. Staff interviews revealed gaps in communication and documentation, contributing to unmet needs and potential harm.
The facility failed to document 24-hour nursing coverage, as required. On several occasions, the PBJ Staffing Data Report showed gaps in coverage, with the DON working 12-hour shifts but no documentation for the remaining hours. The NHA noted issues with the payroll system preventing proper clock-in for the salaried DON, leading to the deficiency.
The facility did not ensure the dietary manager met the necessary qualifications, as she had not completed the Certified Dietary Manager coursework. The facility had a dietician on-site weekly for 8 hours, and the census was 43.
The facility did not implement a water management program as part of its IPCP to control water-borne pathogens and failed to conduct an annual review of the IPCP. Despite having a Legionella Surveillance policy, the facility did not perform primary prevention strategies. An interview with the former NHA confirmed the lack of review and documentation for the water management program.
A facility failed to complete a discharge summary for a resident discharged to a hospital. The discharge summary, which should have included a recapitulation of the resident's stay, was missing. This was confirmed during an interview with the NHA.
A facility failed to conduct regular safety evaluations of bed rails for a resident, as required by their policy. An observation revealed that the last evaluation was conducted over three years ago, despite the policy mandating annual assessments. An MDS coordinator confirmed the lack of documentation for further evaluations.
A resident with severe cognitive impairment due to alcohol-induced dementia was involved in multiple altercations, yet the facility failed to develop specific interventions or a behavioral care plan. Documentation and communication were inadequate, with no professional evaluation of the resident's behaviors and a lack of consultation with the medical director.
A facility failed to provide necessary social services for a resident with a PASRR Level II, who had a history of cerebrovascular accident, dementia, depression, and bipolar disorder. Despite being cognitively intact, the resident did not receive an annual psychiatric evaluation as recommended. Additionally, the resident expressed dissatisfaction and a desire to move, but there was no documentation or follow-up on this issue. The social worker did not document conversations with residents and referred behaviors to nursing staff, contrary to care plan requirements.
Cold Main Dining Room Temperature
Penalty
Summary
The facility failed to ensure comfortable and safe temperature levels in 1 of 2 dining areas, the main dining room, where the temperature was found below the facility’s stated range of 71 to 81 degrees Fahrenheit. Resident interviews indicated the dining room was sometimes cold, especially during meals, and one resident reported the air conditioner was run all the time in the dining room. Another resident stated the dining room was cold and staff had to provide something for his/her shoulders during meals. During the resident council meeting, six residents reported that the dining room and hallways were always cold. Observation on 6/15/26 showed the main dining room felt cold, with 9 residents present; 1 resident wore a coat, 1 had a blanket around his/her shoulders, and 2 residents had blankets on their laps. Later observations showed the dining room felt much colder than the area outside it, and temperatures measured in the main dining room were 68.6 degrees Fahrenheit near the kitchen and 66.8 degrees Fahrenheit at table height closest to the kitchen. The air vent closest to the kitchen was measured at 46 degrees Fahrenheit blowing into the dining room. The maintenance director confirmed the temperature was colder than 71 degrees Fahrenheit. The facility policy stated it would maintain comfortable and safe temperature levels and strive to keep common resident areas between 71 and 81 degrees Fahrenheit.
Failure to Provide Timely Incontinence and ADL Care to Dependent Resident
Penalty
Summary
The facility failed to provide timely ADL and incontinence care to a dependent resident who was cognitively intact but non-ambulatory and unable to perform ADLs independently following a recent above-the-knee amputation. The resident’s care plan documented dependence on staff for incontinence care, with interventions specifying incontinence care after each incontinent episode and that ADL needs would be met each day. On one observed occasion, the resident’s call light was on and an unidentified staff member entered the room, was informed that two staff were required to provide care, then left while the call light remained on. When the same staff member later re-entered the room, they turned off the call light and exited without providing care. The resident reported having waited approximately 45 minutes for the return of two staff members to provide incontinence care and to take them to the shower, and stated it was not unusual to wait an hour or more for incontinence care. Subsequent observation showed three CNAs entering the room with a mechanical lift and providing incontinence care; the resident’s gown and bedding were wet, and the mattress was also wet. CNA interview at that time confirmed the resident’s brief and gown were wet. The DON stated that anyone requiring assistance receives the care they need and that staff were expected to answer call lights and provide incontinence care at the time of need. The facility’s incontinence policy stated that all incontinent residents would receive appropriate treatment and services.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in actual harm to two residents with severe cognitive impairment. In one incident, a resident with dementia and a BIMS score indicating severe cognitive impairment was grabbed by another resident while attempting to take their food tray, resulting in visible bruising and redness on the arm. This was observed by a CNA and confirmed by an RN who assessed the injuries. The facility's investigation and interviews confirmed the occurrence of the incident. In a separate incident, another resident with severe cognitive impairment, non-traumatic brain dysfunction, and dependent on staff for transfers, was found yelling for another resident to leave their room. A CNA responded and found the aggressive resident leaning over the affected resident, who had a red mark on their cheek and reported being slapped. The incident was confirmed through staff interviews and facility investigation. Both incidents demonstrate a failure to ensure residents' right to be free from physical abuse as outlined in the facility's abuse prevention policy.
Failure to Provide Scheduled Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
A resident with diagnoses including hypertension, diabetes mellitus, and arthritis, who was cognitively intact and wheelchair bound, required partial to moderate assistance with bathing and had a care plan indicating the need for help with activities of daily living (ADLs) due to weakness and pain. Despite being scheduled for showers three times weekly and having requested this frequency at admission, the resident reported going several days without a shower, a fact corroborated by their representative. The facility's bathing records showed gaps where the resident was neither provided nor offered a shower for periods of 9 and 10 consecutive days. Interviews with the Director of Nursing (DON) confirmed that there was no documentation of showers being offered or provided during these periods, and that staff were expected to document both bathing and any refusals. Facility policies required that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, and that showers be provided per request or schedule. The lack of documentation and failure to provide or offer showers as scheduled led to the deficiency in maintaining the resident's personal hygiene.
Failure to Honor Residents' Right to Manage Personal Funds
Penalty
Summary
The facility failed to honor the residents' right to manage their personal funds, as evidenced by the review of trust fund account statements for two residents. For the first resident, multiple instances were identified where payments from the Social Security Administration (SSA) were deposited into the resident's account, but subsequent payments to the facility left the resident with no balance or a negative balance, without evidence of the resident receiving their $50 personal needs allowance. This pattern was observed over several months, indicating a consistent failure to allocate the personal needs allowance to the resident. Similarly, for the second resident, SSA payments were deposited into the resident's account, but payments to the facility left the resident with insufficient funds to cover the $50 personal needs allowance. Additionally, after the resident was discharged, the facility continued to receive SSA payments, which were used to pay the facility, leaving the resident with a zero balance. An interview with the former administrator revealed that the residents' personal funds allowances were being used to pay down large debts owed to the facility, contrary to the residents' rights and Medicaid requirements.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with memory problems and diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and dementia, who was sitting at a table in the dining area when another resident approached and struck them on the face. Staff were unaware of the altercation until the resident called out, as they had their backs turned at the time. The resident was assessed with no immediate injury, but a bruise was noted the following day. Surveillance footage confirmed that the attack was unprovoked. The resident who committed the abuse had a history of verbal and physical aggression towards both staff and other residents, as documented in their progress notes. Despite this history, the resident was left unsupervised, which allowed the altercation to occur. The facility's incident report noted that the aggressor was calm and engaged in a puzzle before and after the incident, indicating a lack of immediate provocation or warning signs. The facility's policy on abuse, neglect, and exploitation emphasizes the need for trained and qualified staff to identify and intervene in situations where abuse is likely to occur. However, the incident revealed gaps in staff supervision and awareness, as well as a failure to adequately address the behavioral issues of the aggressive resident. The performance improvement plan identified several root causes, including insufficient staff education on behavioral health, lack of documentation, and poor communication between nursing staff and physicians.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to develop and implement policies and procedures for ensuring the timely reporting of suspected abuse, neglect, or theft, specifically regarding the reasonable suspicion of a crime. This deficiency was identified in two of five sample residents reviewed for allegations of abuse. The facility's policy, implemented on 5/30/23, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. However, a resident-to-resident altercation on 12/9/24 was reported to facility administration promptly but was not reported to the state survey agency until 12/12/24, exceeding the required timeframe. Similarly, another altercation on 12/25/24 was reported to administration promptly but was not reported to the agency until later that day. Interviews with the former administrator, the current administrator, and the social service director confirmed that the allegations were not reported within the required timeframe.
Deficiencies in Behavioral Health Care for Residents with Dementia
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with dementia, resulting in actual harm to one resident. Resident #97, who had non-traumatic brain dysfunction and non-Alzheimer's dementia, exhibited aggressive and combative behaviors over several months. Despite a physician's verbal order for a psychological evaluation, there was no evidence that the evaluation was completed. The resident's care plan lacked effective interventions for managing aggressive behaviors, and the facility did not document attempts to schedule the evaluation or the neurologist's progress notes. The resident's behavior escalated to the point where staff had to barricade themselves and other patients for safety, leading to the resident's removal from the facility by emergency services. Another resident, #4, who had cerebrovascular accident, non-Alzheimer's dementia, depression, and bipolar disorder, expressed suicidal ideations through notes and verbal statements. Despite these indications, there was no follow-up documentation or evidence of effective interventions. The resident's care plan included redirection and monitoring, but the facility lacked a current policy on suicidal behaviors. The mental health agency had stopped seeing the resident, and the facility was waiting for guidance on how to proceed, leaving the resident without adequate support. Interviews with facility staff revealed gaps in documentation and communication regarding the residents' behavioral health needs. The NHA confirmed the lack of documentation for scheduling attempts and progress notes, while the social worker admitted to not documenting conversations with residents. The facility's failure to address these deficiencies in behavioral health care and services contributed to the residents' unmet needs and potential harm.
Deficiency in 24-Hour Nursing Coverage Documentation
Penalty
Summary
The facility failed to maintain a system to document licensed nurses on duty 24 hours a day, as required. A review of the PBJ Staffing Data Report revealed that on multiple occasions in July, October, November, and December, the facility did not provide continuous nursing coverage. Specifically, on certain days, the Director of Nursing (DON) was scheduled for 12-hour shifts, but there was no documentation to confirm coverage for the remaining hours. The Nursing Home Administrator (NHA) acknowledged the issue, noting that the previous PBJ data entry person was no longer employed, and the current system did not allow the salaried DON to clock in without payroll complications. This lack of documentation led to the deficiency in ensuring 24-hour nursing coverage.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager met the required qualifications. During an interview, the dietary manager disclosed that she had not completed the Certified Dietary Manager coursework, although she planned to complete it soon. The facility census was 43, and it was noted that a dietician was present on-site every Tuesday for 8 hours.
Failure to Implement Water Management Program and Review IPCP
Penalty
Summary
The facility failed to implement a comprehensive water management program as part of its Infection Prevention and Control Program (IPCP) to prevent, detect, and control the risk of water-borne pathogens. The IPCP policy, which was implemented on May 22, 2023, lacked evidence of an annual review and necessary updates. Additionally, the facility did not perform primary prevention strategies for Legionella, despite having a policy in place since May 2021. These strategies were supposed to include diagnostic testing, investigation for a facility source of Legionella, and physical and temperature controls. An interview with the former Nursing Home Administrator (NHA) confirmed that the IPCP policy had not been reviewed in the past year, and there was no documentation to show that the water management program had been implemented.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to a short-term general hospital. The medical record review and staff interview revealed that the discharge summary, which should have included a recapitulation of the resident's stay, was not completed. The resident was admitted to the facility and discharged without an anticipated return. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Conduct Regular Bed Rail Safety Evaluations
Penalty
Summary
The facility failed to ensure regular safety evaluations of bed rails for a resident. During an observation, it was noted that a resident had assist bars at the head of the bed, but the last safety evaluation for these assist bars was conducted over three years ago. The facility's policy requires that safety assessments be conducted annually, but an interview with the MDS coordinator confirmed that no further documentation of such assessments was available. This oversight indicates a lapse in adhering to the facility's policy on the regular evaluation of assistive devices for safety.
Deficiency in Dementia Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with dementia, resulting in a deficiency in care. The resident, who had severe cognitive impairment due to alcohol-induced persisting dementia, was involved in multiple resident-to-resident altercations over several months. Despite these incidents, the resident's care plan lacked specific interventions to address these behaviors. The care plans for cognitive loss/dementia and behavioral symptoms included general interventions but did not effectively address the resident's aggressive behaviors. Additionally, the facility did not develop a behavioral care plan or conduct a professional evaluation of the resident's behaviors. The facility's documentation and communication regarding the resident's care were inadequate. Progress notes indicated that the resident was somnolent due to strong medications, yet no assessment or behavioral care plan was developed. A scheduled counseling appointment was canceled due to the resident's combative behavior and lack of clarity about the appointment details. During an interdisciplinary care plan conference, the resident's behaviors were not discussed, and the social worker involved in the resident's care did not document encounters in the resident's record. The former nursing home administrator confirmed that there was no system in place to ensure a professional evaluation of the resident's behaviors, and the medical director had not been consulted.
Failure to Provide Medically Related Social Services for Resident with PASRR Level II
Penalty
Summary
The facility failed to provide medically related social services for a resident with a PASRR Level II, as identified through a review of medical records, staff interviews, and policy reviews. The resident, who was readmitted from the hospital, had a history of cerebrovascular accident, non-Alzheimer's dementia, depression, and bipolar disorder, and was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for suicidal ideations, such as redirection and offering to contact a counselor or family. However, the PASRR Level II recommendations for rehabilitative services, including supportive counseling and an annual comprehensive psychiatric evaluation, were not followed, as there was no evidence of an annual psychiatric evaluation in the resident's medical record. Additionally, a progress note indicated that the resident expressed dissatisfaction with the facility and a desire to move, which was reported to the social services director and the DON, but there was no documentation or follow-up on this conversation. An interview with the social worker revealed that she did not document conversations with residents and would refer any resident behaviors to the nursing staff. The social worker also indicated that care plan interventions should be documented in the progress notes, which was not done in this case.
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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.
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