Summitview Rehab and Health Center

In the surveyor’s words

From the most serious findings on record at Summitview Rehab and Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 15, 2023

  Based on observation, interview and record review, the facility failed to ensure that 1 of 1 resident (Resident 1) was not left unattended on the side of the bed to administer their own breathing treatment prior to assessing the resident's condition/respiratory status, when they experienced an acute change of condtion with significant changes in breathing, had expressed anxiety and signs of respiratory distress. This failure caused actual harm and a potential life-threatening situation for Resident 1 due to being left alone during their respiratory distress and was later found on the floor, unresponsive, with bruising to the face and a hematoma to the right side of their head (a pool of mostly clotted blood that forms in the tissue due to a broken blood vessel caused by injury). […]

• Actual harm, isolatedF689Mar 24, 2026

  Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls with injury, was provided adequate supervision to prevent accident hazards. Resident 1 experienced harm when they were left alone on the toilet and found on the bathroom floor after an unknown amount of time. The fall resulted in a forehead hematoma (a pooling of blood in the surrounding tissues after an injury to the blood vessels) with bleeding, and transfer to the hospital where they were diagnosed with a brain bleed. Failure to identify residents that need supervision while on the toilet put residents at risk for injuries and diminished quality of health. […]

• Actual harm, isolatedF689Jan 24, 2025

  Based on interview and record review, the facility failed to implement interventions to prevent injuries or falls, during resident transfers (helping residents move safely from one place to another) for 2 of 5 residents (Resident 1 and Resident 4) reviewed for falls or injuries acquired during transfers by staff. Resident 1 experienced harm when the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in pain and ankle fractures and put residents that require transfer assistance at risk for injury. […]

• Actual harm, isolatedF686Jun 12, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice to prevent facility acquired pressure injury (PI) and worsening of PIs for 2 of 3 residents (Residents 49, and 18) reviewed for PIs. Resident 49 experienced harm when they developed a stage 4 medical device-related PI (MDRPI) to their right lower leg from an immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) that became infected and resulted in extreme pain. Resident 18 experienced harm when they developed a right buttock PI that worsened, became infected, and required antibiotic treatment. […]

• Actual harm, isolatedF689May 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure accident prevention by identifying and evaluating potential accident hazards for 1 of 1 resident (Resident 4), reviewed for falls. Resident 4 had a mechanical lift recliner with a handheld remote, placed in their room without an evaluation to determine if they were safe to use it. This failure caused actual harm to Resident 4, who used the handheld remote to raise the lift recliner to its highest upright position, fell , and sustained a fracture to the right knee and tibia (the shinbone) from the remote lift chair. Findings included . Resident 4. […]