Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summit Health And Living during CMS and state inspections, most recent first.
A resident with vascular dementia, anxiety, and post-stroke impairments, who depended on staff for most ADLs, was repeatedly denied the ability to hold the showerhead during bathing despite a care plan directing staff to encourage maximal resident participation. On one occasion, a CNA was described as rude and demanding, moved the resident away from the water, told him he was not allowed to have the showerhead, and engaged in a tug-of-war when he reached for it, upsetting the resident. Documentation and staff interviews showed no care plan or assignment sheet restriction on showerhead use, while behavior notes recorded multiple prior instances where the resident was refused the showerhead, and other staff, including the MDS Coordinator and DON, stated the resident should have been allowed to use it.
A resident with vascular dementia, anxiety, prior stroke, and moderate cognitive impairment, who depended on staff for bathing and hygiene, was subjected to verbal abuse by a CNA during shower care. The CNA pushed the resident into a shower corner away from the showerhead, refused to let the resident use the showerhead, threw a washcloth at the resident while telling him to wash his “junk,” and engaged in a tug-of-war over the showerhead, jerking it away. The resident became upset and reported that other caregivers allowed him to participate in his own care, while this CNA dumped shampoo on his head and would not place it in his hand. A QMA present during the incident observed the CNA’s rude and demanding behavior, considered the encounter abusive, but did not intervene, despite facility policy stating residents must be free from verbal and other forms of abuse.
A resident with vascular dementia, moderate cognitive impairment, and significant ADL dependence was verbally mistreated during a shower when a CNA moved the resident away from the showerhead, refused to allow its use, threw a washcloth at the resident, told the resident to wash his "junk," and engaged in a tug-of-war over the showerhead, which the CNA jerked away. Another staff member (a QMA) witnessed the encounter, considered it abusive, but did not intervene to stop the CNA or separate the CNA from the resident and did not immediately report the suspected abuse to the Administrator or DON as required by policy, instead reporting it the next day. Other CNAs reported the resident was typically allowed to use the showerhead and participate in care, and one CNA stated that this CNA had not been nice to the resident in the past but had never reported those concerns.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A facility failed to ensure a cognitively intact resident completed their own advance directives. Despite being alert and oriented, the resident's POST form was signed by a representative. Staff interviews confirmed the resident's mental competence, but the facility lacked documentation of the resident's refusal to sign or attempts to reapproach them. The DON and Administrator could not provide evidence of the refusal or a policy on advance directives.
A resident with dementia was inappropriately started on quetiapine, an antipsychotic medication, without proper indication. Despite exhibiting behaviors like yelling and agitation, the facility's care plan included non-pharmacological interventions, which were not fully exhausted before the medication was prescribed. The facility's policy required a comprehensive assessment and multiple non-pharmacological approaches before using such medications, which was not adhered to in this case.
A facility failed to administer a pneumococcal vaccination to a resident who had consented to it, despite the absence of a current medical contraindication. The resident, with a history of dementia and pneumonia, was due for a PCV 20 vaccine but did not receive it due to a past reaction and illness at the time of consent. The facility's policy requires vaccinations unless contraindicated, but the vaccination was not administered, resulting in non-compliance.
Failure to Honor Resident Choice and Independence During Bathing
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to make choices and to promote independence in ADLs during bathing. On one occasion, a QMA reported that a CNA requested assistance with showering a resident and, during the shower, was rude and demanding. The CNA moved the resident into a corner away from the showerhead and, when the resident reached for the showerhead, told him he was not allowed to have it and that staff had been told he could not have it. When the resident again reached for the showerhead, the CNA and the resident engaged in a tug-of-war over it. The QMA stated she had never been told the resident could not have the showerhead and that this restriction was not in the resident’s care plan. The resident later reported being upset by the incident, identified the CNA involved, and stated that this staff member would not give him the showerhead, although he was not physically harmed and generally liked to do as much for himself as possible. Record review showed the resident had vascular dementia without behavioral disturbance, anxiety, and a history of cerebral infarction with impaired function on the left side, and was dependent for multiple ADLs including bathing, dressing, and transfers. The current ADL care plan directed staff to encourage the resident to participate to the fullest extent possible with each interaction and did not include any intervention restricting his use of the showerhead. The CNA assignment sheet for the date of the incident also lacked any indication that the resident should not be allowed to hold the showerhead. Behavior progress notes documented four prior instances in which the resident was not allowed to have the showerhead after asking for it. Other staff, including another CNA, the MDS Coordinator, and the DON, indicated they were unaware of any restriction and that the resident should have been or was allowed to have the showerhead, with some aides reportedly denying it because the resident had sprayed staff during showers. The facility identified this as a resident rights violation related to self-determination and dignity.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA during shower care. During a shower, a QMA reported that the CNA was rude and demanding, pushed the resident into the corner of the shower away from the showerhead, and refused to allow the resident to use the showerhead, stating staff had been told not to let him have it. The QMA indicated she had never been told the resident could not have the showerhead. When the resident stated he needed to urinate, care was paused and then resumed. The CNA then threw a washcloth at the resident and told him to wash his “junk,” while the QMA assisted the resident with cleaning his private area. The resident reached for the showerhead again, and the CNA and resident engaged in a tug-of-war over the showerhead, with the CNA jerking it away from the resident. The resident, who had diagnoses including vascular dementia without behavioral disturbance, anxiety, and a prior cerebral infarction, was documented as moderately cognitively impaired with impaired function on the left side and dependence on staff for toilet hygiene, bathing, dressing of the lower body, footwear, personal hygiene, and transfers. His care plan included maintaining a consistent routine and caregivers to decrease confusion. During the incident, the resident became upset, expressed that he did not think he had done anything wrong, and stated that he had never been told he could not have the showerhead. He also stated that other staff allowed him to do what he could for himself and then assisted him. The facility’s self-reported incident and interviews corroborated that the CNA refused to allow the resident to use the showerhead, took it away from him, threw a washcloth at him, and used a sarcastic tone when responding to his thanks after the shower. The resident reported that the CNA had jerked the showerhead away, dumped shampoo on his head instead of into his hand, and told him to wash his “junk,” while other caregivers allowed him to participate in his own care. The QMA present during the incident considered the encounter abusive, noted the resident was upset, and did not intervene to stop the CNA or ask her to leave. The facility’s policy states that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, exploitation, involuntary seclusion, mistreatment, neglect, and misappropriation of property, and that residents must not be subject to abuse by anyone.
Failure to Protect Resident From Verbal Abuse and Timely Report Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff intervened to protect a resident from verbal abuse by a staff member and to report the allegation of abuse in a timely manner to facility leadership and regulatory agencies. Resident B, who had vascular dementia without behavioral disturbance, anxiety, a prior cerebral infarction, moderate cognitive impairment, and left-sided functional impairment, required extensive assistance with ADLs and had care plans addressing impaired cognition and a history of being verbally abusive with staff. These care plans included maintaining consistent routines and caregivers and encouraging the resident to participate in care to the fullest extent possible. There was no care plan or assignment sheet indication that the resident was restricted from using the showerhead. On the date of the incident, CNA 1 and QMA 2 were providing a shower to Resident B when CNA 1 moved the resident into the corner of the shower away from the showerhead and refused to allow the resident to use it, stating staff had been told the resident could not have the showerhead. QMA 2 reported she had never been told this. During the shower, CNA 1 threw a washcloth at the resident and told him to wash his “junk,” and engaged in a tug-of-war over the showerhead, ultimately jerking it away from the resident. Resident B corroborated this account, stating that CNA 1 jerked the showerhead away, dumped shampoo on his head instead of into his hand, threw a washcloth at him, and would not allow him to do what he could for himself, unlike other caregivers. The resident reported being upset by the interaction, used profanity to describe the situation, and identified CNA 1 as a staff member who was not nice and would not give him the showerhead. Despite witnessing this encounter and considering it abusive, QMA 2 did not intervene to stop CNA 1 or remove her from the situation and did not immediately report the suspected abuse to the Administrator or DON as required by facility policy. QMA 2 later stated she did not feel the incident needed to be reported because the resident was not harmed or in distress and that her focus was on avoiding further conflict while continuing care. The incident occurred during the 2:00 p.m. to 10:00 p.m. shift, but was not reported by QMA 2 until the following day, resulting in delayed notification to the Administrator and delayed reporting to regulatory agencies. Additional staff interviews revealed that other CNAs were unaware of any restriction on the resident’s use of the showerhead, that the resident was generally allowed to use it and participate in his own care, and that CNA 1 had previously been “not nice” to the resident, but those concerns had not been reported. Facility leadership confirmed that staff were expected to protect residents first and immediately report suspected or actual abuse, mistreatment, or neglect, and that Resident B was allowed to have the showerhead.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Resident with Decisional Capacity Completed Advance Directives
Penalty
Summary
The facility failed to ensure that a resident with decisional capacity completed their own advance directives. Resident 4, who was cognitively intact and had diagnoses including atherosclerotic heart disease and paroxysmal atrial fibrillation, had a POST form signed by a representative instead of the resident themselves. The resident's clinical record and interviews with staff indicated that the resident was alert, oriented, and capable of making their own decisions. Despite this, the resident's daughter signed the POST form, and there was no documentation of the resident's refusal to sign or any attempts to reapproach the resident for their signature. Interviews with various staff members, including RN 3, LPN 4, QMA 5, and LPN 6, confirmed that the resident was mentally competent and should have signed the advance directives. The Director of Nursing (DON) and the Administrator were unable to provide documentation of the resident's refusal to sign or a facility policy on advance directives. The DON mentioned that the resident's daughter signed the paperwork because the resident refused to sign during the admission process, but there was no evidence of this refusal in the resident's record.
Inappropriate Use of Antipsychotic Medication for Dementia Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia was not started on a routine antipsychotic medication without proper indication. The resident, who was admitted with Alzheimer's disease and moderate dementia with behavioral disturbances, was prescribed quetiapine, an antipsychotic medication, without a documented necessity for its use. The resident's clinical records showed no prior orders for psychoactive medications before the initiation of quetiapine, and the facility's policy required that such medications should only be used when necessary to treat a specific condition as diagnosed and documented in the clinical record. Observations and interviews revealed that the resident exhibited behaviors such as yelling, confusion, and agitation, particularly at night, which were attributed to sundowning. Despite these behaviors, the facility's care plan included non-pharmacological interventions such as providing snacks, engaging in conversation, and offering reassurance. However, these interventions were not consistently effective, and the resident's representative contacted the neurologist, who prescribed quetiapine. The facility staff, including the Director of Nursing, were not involved in the decision to start the antipsychotic medication, and there was no evidence of a comprehensive assessment or multiple non-pharmacological approaches being attempted before the medication was prescribed. The facility's policy on psychotropic medication emphasized the need for extreme caution in using antipsychotic medications in the elderly, requiring that behavioral symptoms present a danger to the resident or others, or cause significant distress to the resident. The report indicates that the facility did not adhere to this policy, as the resident's behaviors, while disruptive, did not pose a significant risk of physical injury to others, and the non-pharmacological interventions were not fully exhausted before resorting to medication. This oversight led to the inappropriate use of antipsychotic medication for the resident.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident received the recommended pneumococcal vaccination, as required by their policy. Resident 8, who had a history of dementia, anxiety, PTSD, major depressive disorder, and pneumonia, was due for a PCV 20 vaccine according to CDC guidelines. The resident had previously received the PPSV 23 and PCV 13 vaccines. Although the resident consented to the PCV 20 vaccine in May 2024, the interdisciplinary team noted that the resident was ill at the time and had a past reaction to the vaccine, leading to a decision to delay the vaccination. The facility's policy mandates that all residents receive the pneumococcal vaccination unless medically contraindicated or previously immunized. However, despite the resident's consent and the absence of a current medical contraindication, the vaccination was not administered. The Director of Nursing indicated an intention to reassess the resident's willingness to receive the vaccine, but this action had not been completed at the time of the survey. This oversight resulted in a failure to comply with the facility's vaccination policy.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Summitville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alexandria Care Center | 6.2 mi | — | 1 | 0 |
| Elwood Health And Living | 11.2 mi | — | 12 | 0 |
| Twin City Health Care | 11.5 mi | — | 0 | 0 |
| University Nursing Center | 11.7 mi | — | 18 | 1 |
| Colonial Oaks Health Care Center | 12.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.