Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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, The during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as evidenced by multiple residents reporting and being observed with live bedbugs and bites, ongoing infestations in several rooms, and inconsistent application of pest control measures such as spraying and heat treatment. Staff interviews revealed that not all rooms were routinely inspected, professional exterminators had not been used for bedbugs in over a year, and clutter and resident refusal further hindered effective treatment.
A resident with cerebral palsy and peripheral vascular disease did not consistently receive or have documented wound care treatments and skin assessments as ordered. Multiple missed or undocumented treatments were identified in the TAR, and weekly skin assessments were not completed as scheduled. Staff interviews revealed that treatments may have been performed but not documented, with workload cited as a barrier, and the DON confirmed expectations for proper documentation and completion of care.
Two residents with pressure ulcers or at risk for skin breakdown did not receive consistent wound care treatments, weekly wound measurements, or full body skin assessments as required by facility policy. Documentation was incomplete or missing for multiple treatments and assessments, and one resident lacked a care plan focus for skin impairment. Staff interviews revealed confusion over responsibilities and cited workload as a barrier to proper documentation.
The facility did not complete thorough fall investigations or root-cause analyses for three residents who experienced falls, as required by policy. Incident reports and medical records were missing critical details, care plans were not updated after falls, and staff interviews confirmed inconsistent documentation and follow-through. The DON acknowledged that RCAs were not documented and that incident reports lacked necessary information.
Failure to Maintain Effective Bedbug Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in live bedbugs being observed in the rooms of six sampled residents out of fifteen. Multiple residents reported seeing live bedbugs in their rooms, experiencing bites, and finding bedbugs on their bodies and belongings. Observations confirmed the presence of live and dead bedbugs in resident rooms and bathrooms, as well as visible bites on several residents. Some rooms were noted to be cluttered, which complicated treatment efforts, and residents reported ongoing issues despite previous treatments. Interviews with residents revealed that some had been bitten by bedbugs, while others had not noticed bites but had seen live bugs in their rooms. Several residents stated that their rooms had been sprayed or treated, but the infestation persisted. Staff interviews indicated that pest control measures were inconsistently applied, with reliance on in-house spraying and heat treatment machines. The facility had not engaged a professional exterminator for bedbugs in over a year, and routine inspections of all rooms were not conducted. Staff also reported challenges in treating rooms due to resident refusal of certain treatments and difficulties in managing clutter. Facility leadership acknowledged ongoing bedbug issues, attributing some of the challenges to new admissions from high-risk populations and a recent change in maintenance personnel. The facility's pest control policy outlined comprehensive steps for managing bedbug infestations, but interviews and observations indicated that these procedures were not consistently followed. The lack of regular inspections, incomplete treatment of affected and adjacent rooms, and inconsistent communication and documentation contributed to the continued presence of bedbugs and resident exposure.
Failure to Complete and Document Wound Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments and skin assessments were completed and documented as ordered for one resident with a history of cerebral palsy and peripheral vascular disease. The resident had multiple physician orders for wound care, including the application of protective gels and ointments to various areas on the lower extremities and feet. Review of the Treatment Administration Record (TAR) revealed numerous instances where treatments were either missed or lacked documentation across different shifts throughout March and April. Additionally, weekly skin assessments were not consistently completed, with a gap noted between 4/10/25 and 4/21/25. Interviews with nursing staff and the Director of Nursing (DON) confirmed that while treatments may have been performed, they were not always documented as required. Staff cited workload and time constraints as reasons for incomplete documentation, and there was uncertainty regarding whether treatments were consistently administered. The DON acknowledged responsibility for ensuring completion and documentation of both treatments and skin assessments, and staff were expected to follow established schedules and policies for wound care and assessment. The resident involved was cognitively intact and had a care plan addressing limited mobility and chronic wounds, including the use of protective boots and regular monitoring for skin issues. Despite these interventions, the facility did not adhere to its own policies for wound assessment and treatment documentation, resulting in missed or undocumented care for the resident's chronic wounds and skin conditions.
Failure to Complete and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments were completed and properly documented, including weekly wound tracking and measuring, for a resident with multiple pressure ulcers. Specifically, one resident admitted with diagnoses including dementia, diabetes mellitus, and hypertension, was under hospice care and had several pressure ulcers at various stages. The facility's records showed missed or undocumented wound care treatments over several shifts, and only one instance of wound measurement was documented by facility staff, despite policy requiring weekly assessments and documentation. Interviews with staff revealed confusion over responsibilities between hospice and facility staff, and a lack of consistent documentation of wound care and measurements. Another resident, admitted with diabetes, fibromyalgia, rheumatoid arthritis, and a history of toe amputation, was at risk for developing pressure ulcers and had a Stage III pressure ulcer upon admission. The facility failed to complete and document weekly skin assessments for this resident, with a gap in full body skin assessments noted in the records. Additionally, this resident did not have a care plan focus for skin impairment, contrary to facility policy and staff expectations. Interviews with nursing staff and the DON confirmed that wound care and skin assessments were expected to be completed and documented according to policy, but these actions were not consistently carried out. Staff cited workload and time constraints as reasons for missed documentation, and there was uncertainty about whether treatments were being performed or simply not recorded. The DON acknowledged the lack of daily wound documentation and incomplete care planning for the resident at risk, as well as the need for both hospice and facility staff to be involved in wound measurement and documentation.
Incomplete Fall Investigations and Lack of Root-Cause Analysis
Penalty
Summary
The facility failed to ensure that fall investigations were complete and thorough, including the completion of root-cause analysis (RCA), for three out of five sampled residents. The facility's own policies required licensed nurses to perform timely assessments, complete detailed fall investigation forms, and document all relevant information in the resident's clinical record after each fall. However, for the residents reviewed, incident/accident reports and medical records were missing critical information such as nurse notes, progress notes, and detailed descriptions of the falls. In several cases, the investigation forms lacked explanations of behavioral concerns, contributing diagnoses, and did not include RCAs. One resident with fibromyalgia and restless leg syndrome experienced two non-injury falls, but the investigation forms did not provide sufficient detail, and no RCA was completed. Additionally, a required positioning bar intervention was not in place during observation, and there was no documentation in the resident's chart related to the falls. Another resident, identified as being at risk for falls due to gait and balance problems, had a fall that was not reflected in the care plan, and the incident report lacked a detailed behavioral assessment and RCA. Similarly, a third resident with Parkinsonism and ataxic gait had a fall that was not documented in the care plan, and the incident report did not include an RCA or a nurse note in the chart. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the completion of fall investigations, documentation, and care plan updates. Staff acknowledged that incident reports were often incomplete, RCAs were not documented, and care plans were not consistently updated after falls. The DON confirmed that there was no specific place on the incident report to document the RCA and that RCAs were shared verbally rather than documented. These actions and omissions resulted in the facility's failure to maintain thorough and complete fall investigations as required by policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clara Manor Nursing Home | 0.6 mi | — | 21 | 1 |
| Bishop Spencer Place, Inc, The | 0.8 mi | — | 0 | 0 |
| Ignite Medical Resort Rainbow Boulevard, Llc | 1.8 mi | — | 0 | 0 |
| Parkway Health Care Center | 2.3 mi | — | 2 | 1 |
| Myers Nursing & Convalescent Center | 3.1 mi | — | 27 | 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.