Summit Hills Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Summit Hills Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 22, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure all items in the refrigerator, freezer, and dry storage were sealed, labeled, and dated. The facility also failed to ensure that hair coverings were used properly. These failures had the potential to affect all 24 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Receiving and Storage, revealed, .Dry foods that are stored after opening have to be labeled and dated .All foods stored in the refrigerator or freezer are covered, labeled and dated (use-by date). The following observations on 01/20/25 at 9:21 AM in the kitchen were made with and verified by the Dietary Manager (DM) and the Director of Dining (DD). 1. […]

• No harm, potential for more than minimal, patternF758Oct 14, 2021

  Based on interview, record review, and facility policy review, the facility failed to ensure target symptoms were identified and monitored for medication efficacy for five of five residents (Resident (R) 1, R3, R11, R12, and R21) reviewed for unnecessary medications. This failure had the potential to affect the lowest possible effective dose and/or gradual dose reductions for any of these five residents receiving psychoactive medications. Findings include: 1. Review of R3's Face Sheet, provided on 10/14/21, showed an admitted [DATE] with medical diagnoses that included cognitive communication deficit; major depressive disorder, severe, with psychotic features; and dementia. […]

• No harm, potential for more than minimal, patternF759Oct 14, 2021

  Based on observation, interview, and review of medication label, the facility failed to ensure a medication error rate of less than five percent, in that three of four Licensed Practical Nurses (LPN)1, LPN2, and LPN4 made three medication errors out of 27 medication opportunities, resulting in an 11.11% error rate. These failures placed residents (R) 1, R2 and R14, at risk to not receive the full benefit of their medication therapy. Findings include: 1. Observation on 10/12/21 at 3:32 PM, LPN1 prepared R1's medications which included [MEDICATION(S)] 3.125 milligram (mg) (a medication to treat high blood pressure and heart failure). Review of the R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF582Jan 30, 2026

  Based on record review, interview, and facility policy review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form in the required time frame for 2 (Resident (R)18 and R50) of 3 residents reviewed for beneficiary notices. Findings included: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised 09/2022, revealed 1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS [Centers for Medicare and Medicaid Services] form 1012) is issued to the resident at least two calendar days before benefits end. A Face Sheet revealed the facility admitted R18 on 11/14/25. […]

• No harm, potential for more than minimal, isolatedF656Jan 30, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized person-centered care plans for 2 (Resident (R)17 and R19) of 2 residents reviewed for respiratory services. Specifically, the facility failed to ensure care plans addressed the use of a non-invasive mechanical CPAP (Continuous Positive Airway Pressure) ventilator for R17 and the use of oxygen for R19. Findings included: 1. A facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated, 7. […]