Summers Healthcare Center

In the surveyor’s words

From the most serious findings on record at Summers Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Oct 26, 2023

  39571 Based 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. […]

• Immediate jeopardy, isolatedF807Aug 20, 2025

  Based 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. […]

• Actual harm, patternF684Aug 20, 2025

  Based 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. […]

• Actual harm, patternF697Aug 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Aug 20, 2025

  Based 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. Findings included: a) On 08/11/2025 at 11:52 AM, the Dining Room observation was initiated by the state surveyor. Nineteen (19) out of twenty residents (20) in the main dining room were served their lunch meal with plastic silverware. On 08/11/2025 at 12:40 PM, Registered Nurse (RN) #81 stated, not usually when asked if they use plastic silverware. […]