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 Summers Healthcare Center during CMS and state inspections, most recent first.
Multiple residents experienced harm due to the facility's failure to recognize and treat changes in condition, follow physician orders for medication administration and monitoring, and ensure dietary safety. Errors included missed side effect monitoring, improper medication administration, lack of documentation, and failure to protect a resident with an NPO order from receiving food, resulting in hospitalization and death.
Staff failed to properly assess, monitor, and treat pain for three residents, including not providing ordered interventions, not notifying the physician of uncontrolled pain, not investigating the cause of increased pain that was later found to be due to fractures, and not ensuring timely pain relief when a prescribed medication was unavailable. These failures resulted in actual harm and were confirmed through record review and interviews.
The facility did not provide a dignified dining experience by serving meals with plastic silverware to most residents due to a shortage of clean utensils. Additionally, a nurse aide entered a resident's room without knocking or announcing, contrary to facility policy, resulting in a failure to maintain resident privacy and dignity.
The facility did not consistently follow posted menus or provide residents with the foods they ordered, resulting in menu substitutions, missing items, and meals not prepared according to recipes. A resident did not receive the double fruit portions or ice cream indicated on his tray ticket, and staff confirmed shortages of key menu items and improper meal preparation.
Surveyors identified that several residents consistently received food that was cold, tough, and did not match the posted menu or their dietary orders. Staff interviews revealed a lack of adherence to recipes and menu planning, and test trays showed food items not prepared as required, with some served below safe temperatures. Residents also reported not receiving alternate menu options and insufficient portions.
A resident with orders for both breakfast and lunch to be sent on dialysis days did not consistently receive both meals, with staff confirming only one meal was typically provided. Additionally, meal service times were inconsistent, and some meal components were missing or delayed, failing to meet residents' needs and preferences.
Surveyors found that staff failed to properly store and label multiple opened food items, including thickened liquids, bread, ice cream, and condiments, in both the kitchen and nourishment pantries. Several items were not sealed, not dated, or lacked use-by dates, contrary to facility policy and professional standards. These practices were confirmed by dietary management and LPNs during the investigation.
Staff failed to follow infection control protocols, including proper hand hygiene and use of PPE, for two residents on transmission-based precautions. An LPN did not perform hand hygiene between glove changes during dressing changes and incontinence care for a resident with ESBL, and a nursing assistant was unaware of updated isolation status. For another resident with C. diff, a nursing assistant entered the room without PPE and used hand sanitizer instead of soap and water after contact, contrary to facility policy.
The facility did not retain required documentation showing that residents or their representatives were educated about and either accepted or refused influenza and pneumococcal vaccines. Immunization reports indicated that some residents received or refused vaccines, but consent or declination forms were missing from their records, as confirmed by the DON.
The facility did not ensure that food service areas and resident rooms were free from flies, as evidenced by flies observed in the kitchen and dishwasher areas and reports from two residents who experienced ongoing fly issues in their rooms. Staff confirmed the presence of flies, and the administrator stated there was no specific pest control policy in place.
A deficiency was cited when a resident's care plan did not include all required elements, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident on a Dysphagia Mechanical Soft diet was served regular-texture foods, including uncut spaghetti and improperly prepared zucchini, which did not meet dietary requirements. Staff failed to follow prescribed recipes and diet guidelines, resulting in the resident being unable to eat the meal provided.
Three residents did not receive meals in accordance with their documented allergies, intolerances, or preferences. One did not receive a prescribed nutritional supplement, another with a fish allergy was denied alternate menu options due to unavailable lunch meat, and a third who disliked pork was served a ham-based meal after menu substitutions. Staff confirmed food shortages and substitutions due to missed orders and staffing issues.
Failure to Provide Necessary Care, Medication Administration, and Dietary Safety
Penalty
Summary
The facility failed to provide necessary care and services by not recognizing and treating changes in condition, not following physician orders for medication parameters, failing to document medication administration, and not ensuring food was provided in the correct form. Multiple residents experienced harm as a result, including one resident who was hospitalized with respiratory failure, urinary tract infection, and aspiration pneumonia after staff failed to assess and notify a physician about abnormal urinary output and repeated episodes of distress. Another resident died after being given food despite an order for nothing by mouth (NPO), with the facility failing to protect the resident from others providing food. Medication administration errors were identified for several residents. Orders for side effect monitoring of psychotropic medications were not completed on multiple occasions, and insulin was held without a physician order. Residents received medications such as Midodrine and gabapentin outside of prescribed parameters, including administration when blood pressure was above the hold threshold and dispensing more doses than ordered. Documentation was lacking for medication and treatment administration, and in some cases, there was no evidence that required monitoring or physician notification occurred after abnormal findings. The facility also failed to ensure that residents' dietary needs were met according to orders. One resident did not receive prescribed hemorrhoid cream, with no documentation to support administration. Another resident with a profound swallowing disorder and NPO order died after choking on food, with the investigation failing to determine how the food was provided and no follow-up education for staff or residents with modified diets. These deficiencies were confirmed through record review, interviews, and observations, and were acknowledged by the Director of Nursing.
Failure to Assess, Monitor, and Treat Pain According to Standards
Penalty
Summary
The facility failed to assess, monitor, and treat pain in accordance with professional standards for three residents, resulting in actual harm. For one resident, nursing staff documented multiple instances of moderate to severe pain over several months but did not provide either non-pharmacological or pharmacological interventions as ordered by the physician. The nurse also failed to assess the pain for location or duration and did not notify the physician of the resident's increased pain, despite clear orders to do so when pain was not controlled or was new in onset. Another resident experienced an increase in pain upon movement and transfers. Although pain medication was administered and later increased, staff did not assess the underlying cause of the pain, which was subsequently found to be due to two fractures. In a separate case, a resident reported numbness and tingling at an amputation site, which was communicated to the physician. The physician indicated the issue would be addressed the following day, but there was no documentation that the resident was evaluated or that treatment was prescribed, and the resident continued to experience symptoms. Additionally, for a resident who was prescribed a new pain medication, staff failed to notify the physician when the ordered medication was unavailable and did not obtain an alternative order, despite the availability of a substitute medication. This resulted in the resident not receiving pain relief in the hours prior to death. These failures were confirmed through record review, staff interviews, and resident interviews, and affected three of eight sampled residents reviewed for pain management.
Failure to Ensure Resident Dignity During Meals and Room Entry
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by providing plastic silverware during meals. On two separate occasions, the majority of residents in the main dining room and residents on the last halls were served meals with plastic utensils due to a shortage of clean regular silverware. Staff interviews confirmed that the kitchen had run out of clean silverware, and the issue persisted until it was brought to the attention of staff by the state surveyor. The use of plastic silverware was observed and acknowledged by multiple staff members, indicating a lapse in maintaining resident dignity during meal service. Additionally, the facility did not follow its own policy regarding resident privacy and dignity when a nurse aide entered a resident's room without knocking or announcing themselves. The incident was observed by a state surveyor and confirmed by the unit manager, who acknowledged that the staff member should have knocked before entering. The facility's written policy requires staff to knock and wait for an answer before entering a resident's room, but this procedure was not followed, resulting in a failure to ensure resident privacy and dignity.
Failure to Follow Menus and Provide Ordered Foods
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received the foods they wanted or ordered, as required. On multiple occasions, the kitchen ran out of key menu items, such as lunch meats and chicken tenders, resulting in substitutions that were not consistent with the posted menus. Staff confirmed that certain items listed as 'Always Available' were not in stock for several days, and that menu substitutions were made without following proper recipes or procedures. For example, zucchini was served boiled and without the required ingredients, rather than being prepared according to the facility's recipe, which called for baking with olive oil, pepper, parmesan cheese, and garlic. Staff also indicated a lack of awareness regarding the existence of recipes for menu items. A resident reported dissatisfaction with the food and was observed receiving a meal that did not match the tray ticket instructions. The resident, who was supposed to receive double fruit portions and vanilla ice cream, instead received only one fruit cup and no ice cream. The resident expressed a preference for fruit and ice cream and stated he would have eaten them if provided. The administrator confirmed that the resident had not received the correct portions as indicated on the tray ticket. These failures demonstrate that the facility did not consistently provide meals as planned or as ordered by residents, affecting the nutritional adequacy and resident choice in meal service.
Failure to Provide Palatable, Properly Prepared, and Appropriately Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and appearance, and did not consistently provide food that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, tough, and did not match the menu or their dietary tickets. One resident stated that the food was always ice cold and not as described on the menu, while another reported not receiving the ordered food due to issues in the kitchen. Residents also indicated that food was left in the hallway before delivery, contributing to it being served cold. During a test tray observation, surveyors noted that the zucchini was not prepared according to the provided recipe, as it was boiled instead of baked, lacked parmesan, and was described as bitter, tough, and rubbery. Staff interviews revealed that recipes and menus were not consistently followed, and some staff were unaware of the existence of recipes. Temperature checks of trays showed food items being served below recommended temperatures. Additionally, residents reported not receiving alternate menu options and insufficient portions, with one resident specifically noting that their breakfast order was not consistently fulfilled.
Failure to Provide Timely and Appropriate Meals for Dialysis Resident
Penalty
Summary
The facility failed to ensure that meals were provided at regular times and did not consistently provide required meals to a resident on dialysis. Specifically, a resident with a physician's order for bagged breakfast and lunch to be sent with him on dialysis days reported that the facility did not consistently send lunch, and sometimes an aide would make one, but this was infrequent. Staff interviews confirmed that only one meal, lunch, was typically sent, and not both breakfast and lunch as ordered. The Treatment Administration Record was initialed to indicate a lunch was sent, but there was no confirmation that both meals were provided as required. Additionally, observations and staff interviews revealed inconsistencies in meal service times, with lunch trays being delivered and served outside of the scheduled meal times. There were also issues with meal components, such as not having enough pears for trays, which were to be sent out later. These practices failed to ensure that meals and snacks were served in accordance with residents' needs, preferences, and requests, and did not meet the requirements for providing suitable and nourishing alternatives for residents who needed to eat at non-traditional times.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple instances of improper food storage and labeling. During a review of facility policies, it was noted that opened food items are required to be dated and stored properly, with specific instructions for dry, refrigerated, and frozen foods. However, observations in the kitchen and nourishment pantries revealed several opened food items, such as thickened liquids, spaghetti, pancake syrup, frozen green beans, chicken pot pie mix, bread, coffee, ice cream, relish, ranch dressing, and nutritional supplements, that were either not sealed, not labeled, or lacked use-by dates. Staff interviews confirmed that these items were not managed according to the facility's own policies, with some items being immediately discarded upon discovery. The deficiency was identified through record review, staff interviews, and direct observation, and it was confirmed by both the Regional Dietary Manager and LPNs responsible for monitoring food storage. The facility census at the time was 102, and the improper storage practices had the potential to affect more than a limited number of residents. No specific residents were identified as being directly affected at the time of the survey, and there were no details provided regarding the medical history or condition of any residents in relation to the deficiency.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in following transmission-based precautions and proper hand hygiene protocols. For one resident with pressure ulcers and an ESBL urinary tract infection, an LPN performed dressing changes and incontinence care without performing hand hygiene between glove changes, despite facility policy requiring hand hygiene when moving between contaminated and clean body sites. The LPN acknowledged not performing hand hygiene during these procedures. Additionally, a nursing assistant was observed feeding the same resident in their room without wearing required personal protective equipment (PPE), such as a gown and gloves, and was unaware of the resident's updated contact isolation status. Another resident, under contact isolation and enteric precautions for C. difficile, was also not provided appropriate infection control measures. A nursing assistant entered the resident's room to deliver and set up a meal tray without donning a gown or gloves, touched the resident and their environment, and upon leaving, used hand sanitizer instead of washing hands with soap and water as required for C. difficile precautions. The nursing assistant believed the precautions only applied to direct care, not tray delivery. The Director of Nursing confirmed that contact enteric precautions applied to all staff entering the room.
Lack of Documentation for Flu and Pneumonia Vaccine Consents
Penalty
Summary
The facility failed to provide and document influenza and pneumococcal vaccinations according to accepted standards of practice. Specifically, the facility did not retain documentation that residents or their representatives received education regarding the vaccines, nor did it retain records indicating whether the vaccines were accepted or refused. This deficiency was identified through record review and staff interview, affecting three out of five residents reviewed for immunizations. The facility's policy required that residents or their representatives complete consent or declination forms for these vaccines, but these forms were missing from the medical records. For the residents involved, immunization reports indicated that some received the influenza vaccine while others refused the pneumococcal vaccine. However, there was no supporting documentation in their records to confirm that informed consent or refusal was obtained, or that education about the benefits and potential side effects was provided. The DON confirmed that the required immunization consents and refusals could not be located, attributing the issue to missing documentation from the prior Infection Preventionist.
Failure to Maintain Pest-Free Food Service and Resident Areas
Penalty
Summary
The facility failed to ensure that food preparation and service areas, as well as resident rooms, were free from visible signs of insects, specifically flies. Observations included flies present in the dishwasher and kitchen areas, including near plates, food, and the tray line. Staff confirmed the presence of flies in these areas. Additionally, two residents reported ongoing issues with flies in their rooms, with one resident keeping a flyswatter on hand and another noting that a nurse had killed multiple flies in the room. The administrator acknowledged that while there was a QAPI initiative for flies and increased pest control services during certain months, there was no specific policy or procedure for pest control in place at the facility.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the survey and was based on a review of the resident's records and care planning documentation. The deficiency was directly related to the absence of a comprehensive, individualized care plan that included all necessary components to meet the resident's needs as required by regulations.
Failure to Provide Diet-Appropriate Food Texture and Preparation
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Dysphagia Mechanical Soft Texture diet was served a regular meal consisting of uncut spaghetti noodles, regular sliced zucchini, and a regular slice of bread. The nurse aide questioned the appropriateness of the meal, noting the resident typically received pureed food, but the Regional Dietary Manager approved the tray as served. The resident was unable to eat the meal, expressing frustration and stating he could not eat the food due to not having teeth and was supposed to receive tomato soup, which was marked out on the tray ticket. Observations confirmed the food provided did not match the resident's dietary needs or the facility's diet order. Further investigation revealed the zucchini was not prepared according to the facility's recipe or the National Dysphagia Diet (NDD) guidelines. The zucchini was boiled, not baked, and was served in large, tough pieces that were difficult to chew and not consistent with the required texture for a mechanical soft diet. Staff interviews indicated a lack of adherence to recipes and menu guidelines, with some staff unaware of the existence of recipes or proper procedures for preparing food to meet specific diet consistencies. The facility's own diet manual and addendum specified requirements for chopped vegetables and mechanical soft diets, which were not followed in this instance.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food in accordance with residents' documented preferences, allergies, and intolerances for three of thirteen residents reviewed. One resident did not receive a prescribed frozen nutritional supplement as indicated on their tray card, and the supplement was only provided after intervention by a state surveyor. Another resident, who reported a fish allergy, requested an alternate sandwich but was told there was no lunchmeat available and did not receive the requested cottage cheese and fruit, instead receiving chicken strips. Staff confirmed that the kitchen had been out of lunch meat for several days. A third resident, who had a documented dislike of pork, received a meal containing ham instead of the expected beef in a macaroni casserole. The resident reported having previously informed staff of this preference and resorted to eating a peanut butter and jelly sandwich instead. The Regional Dietary Manager confirmed that due to staffing issues and a missed food order, the facility had to make emergency substitutions, resulting in the use of ham in place of beef. These incidents demonstrate that the facility did not consistently accommodate residents' dietary needs and preferences as required.
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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 Hinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Main Street Care | 5.7 mi | — | 7 | 0 |
| Lindside Healthcare Center | 13.3 mi | — | 24 | 0 |
| Heritage Hall-rich Creek | 17.7 mi | — | 0 | 0 |
| Lewisburg Healthcare Center | 18.9 mi | — | 11 | 1 |
| Raleigh Center | 19.2 mi | — | 13 | 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.