Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Square during CMS and state inspections, most recent first.
Staff failed to monitor and control the temperature of hot beverages, resulting in two residents suffering burns from hot coffee. One resident with Parkinson's disease was served coffee without the required ice and lid, leading to burns that required hospitalization and a PEG tube. Another resident experienced burns from spilled coffee on two occasions, despite care plan interventions. Dietary staff did not routinely check beverage temperatures, and coffee was served directly from the brewing pot without temperature documentation, contrary to facility policy.
Staff failed to ensure hot beverages were served at safe temperatures, resulting in two residents suffering burns. One resident with Parkinson's disease received coffee without the requested ice, causing severe oral burns and requiring hospitalization and a feeding tube. Another resident experienced burns from spilled coffee on two occasions, despite care plan interventions. Staff did not routinely check beverage temperatures, and coffee was served directly from a pot at high temperatures, contrary to facility policy.
Facility staff failed to maintain an effective QAPI program, resulting in two residents sustaining burns from hot coffee due to lack of temperature monitoring and ongoing oversight. Despite documented incidents and initial action plans, staff did not consistently check beverage temperatures or use temperature-controlled dispensers, and there was no evidence of continued monitoring or follow-up by the QAPI committee.
A review of staff records and interviews revealed that none of the sampled management, CNAs, LPNs, or RNs had received required training on the elements and goals of the facility's QAPI program. Facility leadership confirmed the absence of such training documentation and did not provide further information.
Staff did not post the most recent state survey results in an accessible location for residents and families. The binder available on the unit contained outdated survey reports, and the administrator confirmed the latest results were not posted or accessible as required.
Staff failed to prevent accident hazards related to hot liquids, serving beverages and soups at unsafe temperatures and not following required safety interventions for at-risk residents. This resulted in repeated incidents, including injuries to two residents, one of whom required hospitalization. The administrator did not ensure consistent monitoring or staff compliance with safety protocols, and temperature logs showed ongoing unsafe practices.
Staff did not serve meals to all individuals at the same table at the same time, resulting in some eating before others and causing discomfort among those waiting. Residents expressed dissatisfaction with the lack of a family-style dining experience, and staff acknowledged that all at a table should be served together to promote dignity.
Staff did not update the daily nurse staffing information as required, resulting in the posting of outdated information in a visible area. The responsible employee, who typically updates the posting each morning, did not do so on the day in question, and this was confirmed by both the unit manager and administrator during the survey.
A review of employee records found that the social worker did not have documented training in effective communication. Despite requests, facility leadership could not provide evidence that this required training had been completed.
Surveyors found that two employees did not receive required behavioral health training, as evidenced by a review of staff records and facility documentation. The facility's own assessment indicated the need for staff competencies in behavioral health to care for residents with mental health and behavioral needs, but documentation for these two employees was missing.
Failure to Prevent Burns from Hot Beverages
Penalty
Summary
Facility staff failed to provide an environment free of avoidable accident hazards and did not adequately monitor the temperature of coffee served to residents, resulting in burns to two residents. One resident, who had Parkinson's disease and was assessed as being at risk for spillage due to tremors and weakness in her upper extremities, was served coffee without the required ice and lid. Despite care plan interventions specifying that hot beverages should have lids and be served with ice, the coffee was served directly from the brewing pot, and the temperature was not checked. The resident's husband, who typically fed her and requested coffee with ice, was not aware that the coffee was too hot. The resident sustained burns to her lip and mouth, which led to hospitalization, inability to swallow, and the need for a PEG tube for nutrition. Another resident experienced two separate incidents of spilling hot coffee, resulting in burns. In one incident, the resident spilled coffee on his abdomen and thigh, causing partial-thickness second-degree burns over 2-3% of his body surface area. The care plan for this resident included the use of a cup with a snap-on lid and a clothing protector, but the incidents still occurred. Documentation showed that hot liquid risk assessments were completed, and interventions were recommended, but the facility did not ensure consistent implementation or monitoring of beverage temperatures. Observations and staff interviews revealed that dietary staff did not have a protocol to check the temperature of coffee before serving it to residents. Coffee was routinely served directly from the brewing pot, which had a water temperature of 200 degrees Fahrenheit, and no evidence was found that beverage temperatures were being documented. Staff were unaware of the need to monitor beverage temperatures, and the facility's policy stated that hot beverages should not exceed 155 degrees, but this was not being followed. These failures resulted in harm to residents and led to the identification of Immediate Jeopardy and Substandard Quality of Care.
Failure to Serve Hot Beverages at Safe Temperatures Resulting in Resident Burns
Penalty
Summary
Facility staff failed to provide beverages at a safe temperature, resulting in harm to two residents. In one case, a resident with Parkinson's disease, who had documented tremors and weakness in her upper extremities, was served coffee without the requested ice, leading to severe burns on her mouth and throat. The resident's care plan and risk assessment had specified the need for lids on hot beverages and water-resistant clothing protectors, and her spouse routinely requested coffee with ice and a straw. On the day of the incident, a dietary server, in a rush, forgot to add ice to the coffee, and the resident's spouse, unaware of the omission, gave her the coffee through a straw. The coffee was hot enough to cause immediate pain, blistering, and ultimately required hospitalization, IV fluids, and the surgical placement of a feeding tube due to the resident's inability to swallow. Another resident experienced two separate incidents of spilling hot coffee, resulting in burns. This resident had multiple Hot Liquid Risk Assessments and care plan interventions, including the use of a specific cup with a lid and encouragement to use a clothing protector. Despite these interventions, the resident was served coffee at a temperature that caused partial-thickness second-degree burns over the lower abdomen and upper thigh in one incident, and redness on the thigh in another. The care plan interventions were not sufficient to prevent injury, and the temperature of the coffee was not monitored prior to serving. Observations during the survey revealed that coffee was brewed and served directly from a pot with a water temperature of 200 degrees Fahrenheit, and staff did not routinely check or monitor the temperature of hot beverages before serving them to residents. The facility's policy stated that hot beverage dispensers should not exceed 155 degrees, but this was not consistently followed. Staff interviews confirmed that temperature checks were not routinely performed, and the dietary server involved in the first incident acknowledged forgetting to add ice to the coffee, which was a standing request for the resident. These failures directly led to significant harm for both residents.
Failure to Maintain Effective QAPI Program Leads to Resident Burns from Hot Coffee
Penalty
Summary
The facility staff failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of ongoing monitoring and documentation of corrective actions following multiple incidents where residents sustained burns from hot coffee. Observations revealed that dietary staff did not monitor or record the temperature of coffee being served, despite the coffee maker displaying a water temperature of 200 degrees Fahrenheit. Food temperature logs for the previous week and the day of observation showed no evidence that coffee temperatures were being checked, and staff continued to serve coffee directly from the pot without verifying its safety for consumption. Clinical record reviews identified that two residents suffered harm as a result of this deficiency. One resident experienced two separate incidents of burns from hot coffee, including a significant event resulting in partial-thickness second-degree burns over the lower abdomen and upper thigh, requiring medical intervention and pain management. Another resident sustained burns to the mouth and throat after drinking hot coffee, leading to hospitalization, difficulty swallowing, and the need for a PEG tube for nutrition. In both cases, documentation indicated that the burns were directly related to the temperature of the coffee served and the lack of appropriate safety measures. Despite these serious incidents, the facility's QAPI program did not provide evidence of ongoing monitoring or effective follow-up after initial action plans were created. Interviews with the administrator and COO revealed an inability to explain the process for ensuring continued compliance with implemented interventions. Additionally, surveyors observed that staff were not utilizing temperature-controlled dispensers or monitoring beverage temperatures as outlined in the facility's own action plans, further demonstrating the ineffectiveness of the QAPI program in preventing recurrence of harm.
Failure to Provide QAPI Training to Staff
Penalty
Summary
Facility staff failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff, as evidenced by a review of employee records and staff interviews. A sample of nine employees, including management, CNAs, LPNs, and RNs, was selected for review, and transcripts from the facility's electronic training system were examined. The review revealed that none of the sampled employees had received any training related to the elements and goals of the facility's QAPI program. During meetings with the Administrator, Director of Nursing, and corporate staff, it was confirmed that there was no evidence of QAPI training for any of the sampled staff, and no additional information was provided by facility leadership.
Failure to Post Most Recent Survey Results for Resident and Family Access
Penalty
Summary
Facility staff failed to post the results of the most recent state survey in a location that was readily accessible to residents and families. During observations, a binder labeled with the facility's 2022-2023 Virginia State Survey Results was found in a wall pocket at the entrance to the healthcare unit. The binder contained survey results, but the most recent survey report from February 7, 2025, was not included. Instead, the latest report available in the binder was dated November 15, 2023. When interviewed, the facility administrator stated that survey results had been discussed at a recent resident meeting and that meeting minutes were sent to residents' family members. The administrator also indicated that survey results were posted in a locked glass cabinet on the unit wall. However, upon further inspection, it was confirmed that the most recent survey results were not posted or made accessible as required. The facility was unable to provide a policy regarding the posting of survey results before the conclusion of the survey.
Failure to Prevent Hot Liquid Burns Due to Inadequate Oversight and Unsafe Practices
Penalty
Summary
Facility staff failed to effectively administer operations to prevent accident hazards related to hot liquids, resulting in immediate jeopardy and substandard quality of care. Despite a prior survey identifying the same issue, the facility did not correct the deficiency, and unsafe practices persisted. Observations revealed that hot liquids, such as soup and hot water, were served at temperatures exceeding the facility's own safety policies, with soup measured at 163°F and hot water at 178.5°F. Staff did not consistently check or document temperatures before serving, and there was a lack of clear signage in the kitchen regarding safe serving temperatures. Additionally, staff were observed serving hot liquids to residents without required safety interventions, such as lids on cups, even when care plans and risk assessments specified these precautions. Multiple residents who were assessed as being at risk for injury from hot liquids were not provided with the necessary interventions. For example, one resident with a documented risk for hot liquid injury was served soup in a regular bowl without a lid, and another resident with upper extremity weakness was served hot chocolate without a lid, with the water temperature not checked prior to serving. A third resident, also identified as at risk, was served coffee without a lid, contrary to her care plan. These failures occurred despite the facility's policy and care plans requiring specific interventions to minimize the risk of burns and injuries from hot liquids. Review of food temperature logs showed repeated instances of hot liquids being held or served at temperatures above the facility's identified safe limits, with no evidence of corrective action or consistent monitoring. The administrator acknowledged that compliance monitoring was lacking, and staff were unclear about safe temperature requirements. The administrator also admitted to not regularly auditing temperature logs or directly verifying staff adherence to safety protocols. These ongoing failures led to repeated incidents, including two residents suffering injuries from spilled coffee, one of whom required hospitalization and multiple surgeries.
Failure to Serve Meals in a Dignified Manner During Dining Service
Penalty
Summary
Facility staff failed to serve meals in the dining room in a manner that promoted dignity for three residents. During lunchtime observations, one resident at a table with two others received her meal, ate, and left before the other two residents at the same table were served. Another resident was observed waiting with her food, choosing not to eat until the others at her table were also served. Residents expressed discomfort with the situation, with one stating she was hungry but needed to be patient, and another expressing dislike for eating while others at her table had not yet received their meals. Staff interviews confirmed that the expectation was to serve all residents at a table before moving to the next, in order to maintain dignity and a family-style dining experience. The executive chef acknowledged the importance of serving one table at a time, and the administrator expressed disappointment upon learning of the observed practice. The deficiency was identified through direct observation and resident interviews, with no additional information provided prior to the exit conference.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post the required daily nurse staffing information in a location visible to residents and visitors on one unit. During a walkthrough, a surveyor observed that the staffing information displayed was for the previous day, not the current day as required. Interviews with the unit manager, a registered nurse, revealed that a specific staff member is responsible for updating the posting each morning upon arrival at 7:30 a.m., but on this occasion, it had not been updated. The administrator and unit manager confirmed the oversight when they accompanied the surveyor to the lobby and saw the outdated posting. The director of nursing and administrator both stated that the posting should be updated by the start of visiting hours at 8 a.m., but this had not occurred on the day of the survey.
Lack of Effective Communication Training for Social Worker
Penalty
Summary
Facility staff failed to provide credible evidence that the social worker received training in effective communication, as required. During an extended survey, a sample of nine employee records was reviewed for compliance with training requirements, specifically in the area of effective communication. The review revealed that the social worker's record did not contain documentation of such training. When asked, the facility administrator was unable to provide any additional information or evidence to demonstrate that the social worker had completed the required training. These findings were discussed with facility leadership, and no further documentation was submitted prior to the exit conference.
Failure to Provide Behavioral Health Training to All Required Staff
Penalty
Summary
Facility staff failed to provide behavioral health training to two of nine employees reviewed during an extended survey. The surveyors requested evidence of behavioral health training for a sample of nine employees, but the facility was unable to provide credible documentation that two of these employees had received the required training. This deficiency was identified through staff interviews, staff record reviews, and facility documentation review. The facility assessment, last reviewed shortly before the survey, indicated that the facility provides care for residents with mental health and behavioral needs, including those with psychiatric symptoms, cognitive impairment, depression, trauma/PTSD, and other related diagnoses. The assessment also specified that staff should possess competencies in behavioral health to support residents with mental and psychosocial disorders. Despite these requirements, the facility did not have evidence that all staff had received the necessary behavioral health training as outlined in their own assessment.
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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 Waynesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Edge Rehabilitation And Nursing | 1.3 mi | — | 0 | 0 |
| Augusta Nursing And Rehabilitation | 3.9 mi | — | 0 | 0 |
| Shenandoah Nursing Home | 4.5 mi | — | 0 | 0 |
| Augusta Medical Ctr Skilled Ca | 5.2 mi | — | 0 | 0 |
| Staunton Post Acute & Rehabilitation | 10.7 mi | — | 6 | 1 |
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