Summit Square

In the surveyor’s words

From the most serious findings on record at Summit Square, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 7, 2025

  Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment free of avoidable accident hazards and failed to monitor coffee temperatures to prevent burns, resulting in harm for two residents (Resident #4- R4 and Resident #2-R2) in a survey sample of five residents. These findings led to the identification of Immediate Jeopardy (IJ) and the identification of Substandard Quality of Care. The findings included: On 2/5/25, during a review of facility documentation, it was noted that on 6/13/24, Resident #4 (R4) was served coffee which resulted in a burn to her lip and roof of her mouth, requiring hospitalization . On 2/5/25, a closed record review was conducted of R4's chart. […]

• Actual harm, isolatedF804Feb 7, 2025

  Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide beverages at a safe temperature to prevent injury, which resulted in harm for two residents (Resident #4 - R4 and Resident #2 - R2) in a survey sample of five residents. The findings included: 1. For Resident #4 (R4), the facility staff served coffee at a temperature that resulted in significant burns and scalding, which developed into a life-threatening injury that required hospitalization and the surgical placement of a feeding tube. […]

• Actual harm, isolatedF865Feb 7, 2025

  Based on staff interview, clinical record reviews, and facility documentation review, the facility staff failed to implement and maintain an effective quality assurance and performance improvement (QAPI) program, and failed to provide evidence necessary to demonstrate compliance with these requirements, which resulted in harm for two residents (Resident #2 and Resident #4) in a survey sample of five residents. The findings included: On 2/5/25 at 11:40 a.m., an observation was conducted of the on-unit kitchenette where the coffee is prepared. The cook (other employee #1- OE #1) was observed taking the temperature of food items, which included the soup at 174 degrees farenheight and hotdog chili that was 175 degrees farenheight. […]

• No harm, potential for more than minimal, widespreadF944Feb 7, 2025

  Based on staff interview and employee record reviews, the facility staff failed to provide QAPI (Quality Assurance and Performance Improvement) training to 9 of 9 sampled employees reviewed for educational requirements. The findings included: On 2/6/25, a sample of nine employees was selected from a listing of current staff. The sample included management staff, CNAs (certified nursing assistants), LPNs (Licensed practical nurses) and RNs (registered nurses). The facility administrator was given the names of the nine sampled staff and was asked to provide all education and in-service training for those employees to include evidence of QAPI training. On 2/7/25, the facility provided a transcript for an electronic training system for the sampled employees. […]

• No harm, potential for more than minimal, patternF812Dec 3, 2025

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in a sanitary manner in the main kitchen and on the on-unit kitchen on the one nursing unit having the potential to affect many residents on the one healthcare unit. The findings included:12/1/25 at 6:02 pm, an observation was conducted of the galley kitchen, located on the healthcare unit. Upon entering the galley kitchen, it was observed that on the beverage table there were 3 partial loaves of bread, open without any date as to when it was opened or to be used by. In the reach-in freezer there was a large container of ice cream that was open to air and had no indication of when it had been opened or was to be used by. […]