Deficiency Records for Summit Health and Rehab Center

(Home page)

Updated as of April 01, 2024

A list of the most recent deficiencies for Summit Health and Rehab Center. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-01-05 2024-02-13 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-01-05 2024-02-13 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-01-05 2024-02-13 Y
Ensure that residents are free from significant medication errors. Health 2024-01-05 2024-02-13 Y
Properly install and monitor supervisory attachments on automatic sprinkler systems. Fire Safety 2022-05-06 2022-12-01 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-05-06 2022-07-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-05-06 2022-07-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-05-06 2022-07-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-05-06 2022-07-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-05-06 2022-07-15 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-04-21 2022-06-04 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-04-21 2022-06-04 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-04-21 2022-06-04 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2022-04-21 2022-06-04 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-04-21 2022-06-04 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-04-21 2022-06-04 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-04-21 2022-06-04 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-21 2022-06-04 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-04-21 2022-06-04 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2022-04-21 2022-06-04 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-04-21 2022-06-04 N
Ensure that residents are free from significant medication errors. Health 2022-04-21 2022-06-04 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 2022-04-21 2022-06-04 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2022-04-21 2022-06-04 N
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Health 2022-04-21 2022-06-04 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2022-04-21 2022-06-04 N
Provide and implement an infection prevention and control program. Health 2022-04-21 2022-06-04 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-04-21 2022-06-04 Y
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2019-10-31 2019-12-16 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-10-31 2019-12-16 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-10-31 2019-12-16 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-10-31 2019-12-16 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-10-31 2019-12-16 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-10-31 2019-12-16 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2019-10-31 2019-12-16 N
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Health 2019-10-24 2019-12-05 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-10-24 2019-12-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-10-24 2019-12-05 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2019-10-24 2019-12-05 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 2019-10-24 2019-12-05 N
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 2019-10-24 2019-12-05 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2018-08-23 2018-10-05 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2018-08-23 2018-10-05 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2018-08-23 2018-10-05 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-08-23 2018-10-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-08-23 2018-10-05 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-08-23 2018-10-05 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2018-08-23 2018-10-05 N
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 2018-08-23 2018-10-05 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2018-08-23 2018-10-05 N
Have elevators that firefighters can control in the event of a fire. Fire Safety 2018-09-18 2018-10-04 N