Deficiency Records for Summit Commons Rehabilitation and Health Care Cnt
Updated as of April 01, 2024
A list of the most recent deficiencies for Summit Commons Rehabilitation and Health Care Cnt. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep all essential equipment working safely. | Health | 2023-12-21 | 2024-01-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-19 | 2023-07-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-22 | 2023-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-19 | 2023-02-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-19 | 2023-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-02-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-22 | 2023-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-22 | 2023-01-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-22 | 2023-01-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-22 | 2023-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-22 | 2023-01-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-12-22 | 2023-01-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-22 | 2023-01-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-01-21 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-22 | 2023-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-01-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-22 | 2023-01-21 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-22 | 2023-01-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-21 | 2023-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-21 | 2023-01-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-21 | 2023-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-21 | 2023-01-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-24 | 2022-11-17 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-10-24 | 2022-11-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-24 | 2022-11-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-24 | 2022-11-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-24 | 2022-11-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-29 | 2022-09-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-29 | 2022-09-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-11 | 2022-08-31 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-27 | 2022-08-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-27 | 2022-08-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-18 | 2022-08-12 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-22 | 2022-07-01 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-14 | 2022-07-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-12 | 2022-04-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-08 | 2021-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-08 | 2021-11-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-28 | 2021-11-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-10-28 | 2021-11-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-28 | 2021-11-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-10-28 | 2021-11-12 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-28 | 2021-11-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-01 | 2021-09-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-01 | 2021-09-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-01 | 2021-09-21 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-29 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-09-30 | N |
