The Summit

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 14, 2023

  Based on record review, observation, and interview the facility failed to provide adequate supervision of a cognitively impaired resident to prevent elopement for 1 (#2) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice resulted in an immediate jeopardy situation on 09/11/2023 at 5:10 p.m., when Resident #2, who resided on the facility's locked unit (Hall X), and had been identified as a wanderer with a history of exit seeking behaviors, was left unsupervised while outside smoking. Resident #2 climbed over a wooden fence in the courtyard area, unnoticed by staff, and was found by S7 CNA in the parking lot of a department store 900 feet from facility at approximately 5:46 p.m. on 09/11/2023. […]

• Immediate jeopardy, isolatedF835Sep 14, 2023

  Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 Resident (#2) out of 6 sampled residents (#1, #2, #3, #4, #5, and #6). The facility failed to: 1. Ensure LPN/MDS Nurse accurately assessed Resident #2 who was determined to be at risk for elopement. 2. Have an effective system in place to ensure Resident #2 was adquately supervised to prevent elopement. […]

• Actual harm, isolatedF600Jan 21, 2021

  Based on interviews and record reviews the facility failed to ensure a resident was free from physical abuse from other residents for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed for abuse. This deficient practice resulted in actual harm on 9/11/2020 when resident #2 was attacked by resident #4, a wandering resident with behavioral problems. Resident #4 wandered into the room of resident #2 and physically attacked resident #2. Resident #2, a bilateral AKA, was in bed and not able to protect herself or move from the aggressive attack of resident #4. Resident #2 sustained an injury to her left eye, and was diagnosed with [REDACTED]. […]

• No harm, potential for more than minimal, patternF640Apr 16, 2025

  Based on record review and interview, the facility failed to transmit a Discharge MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #34 and Resident #40) of 2 sampled residents with MDS record over 120 days old. Findings: Resident #34 Review of Resident #34's medical records revealed an admission to the facility on [DATE] and a discharged from facility on 11/19/2024. Reviews of Resident #34 MDS transcription report revealed no Discharge MDS was initiated or completed after discharge. Resident #40 Resident #40 was admitted to the facility on [DATE] and was discharged from the facility on 10/28/2024. Review of Resident #40's MDS transcription report revealed no discharge MDS was initiated or completed. Interview on 04/14/2025 at 03:50 p.m. […]

• No harm, potential for more than minimal, patternF584Mar 6, 2024

  Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The front face coverings for air condition/heater units in rooms a, b, c, d, e, and f were properly secured; 2. The walls in rooms, b, c, e, and f did not have peeling sheet rock; 3. The wall mounted molding near the bedside table in room d, did not have a split in the molding with splinters visible. 4. Handrails on Hall A were cleaned and free of debris and dead insects, and chipped paint was repaired; 5. The floor in Room b had been cleaned of dust and dead insects; and 6. Resident #16's enteral feeding pump was free of dried, splattered feeding. Findings: Room a 03/05/2024 at 9:18 a.m. […]