Summit Health And Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident did not receive an antipsychotic medication without indication when the facility failed to identify targeted behaviors and individualized interventions to support the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 12)Findings include:During an interview with Resident 12's representative on 4/30/26 at 11:08 a.m., she indicated she felt Resident 12 received quetiapine (an antipsychotic) as a babysitter for the facility. The resident just sat around, and the representative felt like he got tired of doing nothing. During an observation on 4/30/26 at 12:24 p.m., staff assisted Resident 12 with lunch. His eyes were closed much of the time, and he would occasionally open them when staff said his name. During an observation on 5/1/26 at 10:49 a.m., Resident 12 sat near the nurse's station. He held a soft activity book with tactile sensory objects and ran his fingers over…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to make choices and to promote independent activities of daily living. (Resident B and CNA 1)Findings include:During an interview on 1/14/26 at 10:50 a.m., QMA 2 indicated on 12/29/25, CNA 1 asked the QMA for assistance showering Resident B. During the shower, CNA 1 was rude and demanding with the resident. CNA 1 moved the resident to the corner, away from the showerhead. During the shower, the resident reached for the showerhead. CNA 1 indicated to the resident that he (Resident B) was not allowed to have the showerhead, and staff were told he wasn't to have it. QMA 2 indicated she had never been told the resident could not have the showerhead, nor was it in his plan of care. The resident reached for the showerhead again. CNA 1 told the resident he was not allowed to have the showerhead, and they began a tug-of-war for the showerhead.During an interview on 1/14/26 at 12:44 p.m., Resident B indicated he was satisfied with his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member (Resident B and CNA 1).Findings include:During an interview on 1/14/26 at 10:50 a.m., QMA 2 indicated, on 12/29/25, CNA 1 asked for assistance showering Resident B. During the shower, CNA 1 was rude and demanding with the resident. CNA 1 moved the resident to the corner of the shower, away from the showerhead. During the shower, the resident reached for the showerhead. CNA 1 told the resident he (Resident B) was not allowed to have the showerhead and staff had been told so. QMA 2 indicated she had never been told the resident could not have the showerhead. During the shower, the resident indicated they needed to urinate. When the resident was finished, they continued with the shower. CNA 1 threw a washcloth at the resident and told him to wash his junk. QMA 2 assisted the resident in cleaning his private area. The resident reached for the showerhead again. CNA 1 told the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff (QMA 2) intervened to protect a resident (Resident B), who was verbally abused by another staff member (CNA 1). The facility also failed to ensure staff reported the allegation of verbal abuse of a resident (Resident B) by another staff member (CNA 1) in a timely manner to the Administrator, resulting in the facility failing to report the suspicion/actual verbal abuse to the appropriate regulation agencies in a timely manner. Findings include:Resident B's clinical record was reviewed on 1/14/26 at 11:31 a.m. Diagnoses included vascular dementia without behavioral disturbance, anxiety, and cerebral infarction due to thrombosis of right posterior cerebral artery.The most current quarterly Minimal Data Set assessment (MDS), dated [DATE], indicated Resident B was moderately cognitively impaired. The resident had impaired function to the left side upper and lower extremities and dependent for toilet hygiene, shower/bathe, dressing of the lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to prevent the neglect of a dependent resident when CNA 1 did not implement the resident's care plan interventions nor follow manufacture's guidelines for the operation of a mechanical lift, resulting in a resident fall when the mechanical lift tipped over during a transfer for 1 of 3 residents reviewed for mobility transfers utilizing a mechanical lift. (Resident B)Findings include:Resident B's clinical record was reviewed on 8/20/25 at 10:10 a.m. Diagnoses included cerebral infarction, vascular dementia, hemiplegia and hemiparesis affecting left non-dominate side, type 2 diabetes, chronic kidney disease, hypertension, anticoagulant use, depressive disorder, and chronic pain syndrome. A current care plan, dated 1/18/21, indicated the resident had an activity of daily living deficit. Interventions included two staff member participation for mobility transfers. The most current quarterly MDS (Minimum Data Set) Assessment, dated 7/10/25, indicated the resident was dependent for transfers to and from a bed to a chair or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure mail was distributed on Saturdays. This deficiency had the potential to affect 32 of 32 residents who resided in the facility. Finding includes: During a Resident Council group interview, beginning on 6/25/25 at 9:40 AM, the Resident Council President indicated residents never got mail on Saturdays because no one worked in the facility's business office on Saturdays. Residents 16, 21, and 31 indicated they did not think they received mail on Saturdays, but were uncertain. During an interview, on 6/27/25 at 9:34 a.m., LPN 3 indicated she worked on the weekends, but she was uncertain if residents received mail on Saturdays. During an interview, on 6/27/25 at 2:13 p.m., the Administrator indicated the facility's mail was delivered to a post office box, and they did not pick up the facility's mail on Saturdays. She did not have anyone to get the mail on Saturdays, so mail was not delivered on Saturdays to the residents. According to the United States Post Office website, accessed on 6/27/25 at 4:39 p.m. at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the activity director completed the required education to meet the qualifications for an activity director. Finding includes: Employee records were reviewed on 6/26/25 at 3:30 p.m. The records lacked documentation of the required training for the Activity Director (AD). During an interview on 6/27/25 at 4:53 p.m., the Administrator indicated that the AD began her position approximately 90 days ago. The AD was not currently certified and was registered for an Activity Director course with a requested date of 7/7/25. Confirmation of the training had not yet been received. The Activity Director consulted with other AD's at sister facilities by zoom meetings or by going to their facilities. There had not been any activities onsite supervision since the previous AD, who departed early April 2025. 3.1 -33(e)

Based on observation, interview, and record review, the facility failed to implement interventions to promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 29) Finding includes: During an observation, on 6/24/25 at 11:28 a.m., Resident 29 sat in his recliner with his feet elevated and wore socks and shoes. He did not wear heel protection boots. During an observation, on 6/25/25 at 9:21 a.m., the resident sat in his recliner with his feet elevated. He did not wear heel protection boots. During an observation, on 6/25/25 at 11:19 a.m., Resident 29 sat in his recliner with his feet elevated. His feet were off the edge of the recliner with the backs of his heels touching the edge of the recliner. He did not wear heel protection boots. During an observation, on 6/25/25 at 4:26 p.m., the resident lay in his bed with his feet covered. His legs and ankles were bare. He did not wear heel protection boots. During an observation, on 6/26/25 at 9:14 a.m., Resident 29 lay in bed with socks on, and his heels were lying on the bed. He did not wear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure nursing staff had competencies for the administration of medications, flushes, and feedings though a gastrostomy tube (feeding tube) for 1 of 6 residents reviewed for medication administration. (Resident 1) Finding includes: During an observation on 6/26/25 at 8:13 p.m., RN 13 performed hand hygiene, then crushed a phenobarbital (for seizures) 60 milligram (mg) tab and placed in approximately 10 milliliters (mg) of water in medication cup, poured out 7.5 ml of levetiracetam (for seizures) solution 100 mg/ml in a medication cup, and opened a 30 ml packet of ProStat (supplement) and placed in a cup and added 120 ml water. Upon entering Resident 1's room, she raised the head of the bed up. She washed her hands, applied gloves, drew up the phenobarbital/water mix in the syringe, attached the syringe to the gastrostomy tube (g-tube), used the syringe plunger and pushed the medication through the g-tube. She drew up water in the syringe, attached the syringe to the g-tube, pushed the syringe plunger to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for 1 of 2 resident reviewed for wound care. (Resident 29) B. Based on observation, interview, and record review, the facility failed to utilize infection control and prevention strategies during handwashing with g-tube medication and feeding administration, hand hygiene with glove use, and insulin administration. Findings include: A. Resident 29's clinical record was reviewed on 6/26/25 at 10:43 a.m. Diagnoses included heart failure, peripheral vascular disease, presence of aortocoronary bypass graft, type 2 diabetes mellitus without complications, and muscle weakness. Current orders included the following: Clean left heel with normal saline. Apply nickel thick layer of Santyl (medication for removal of dead tissue of wound) to wound bed. Cover with saline moistened gauze and foam dressing daily and as needed for soilage/displacement. During an observation, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's advance directives were completed by the resident with decisional capacity for 1 of 16 residents reviewed for advance directives. (Resident 4) Finding includes: Resident 4's clinical record was reviewed on [DATE] at 9:04 a.m. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (thickening and hardening of the artery without chest pain) and paroxysmal atrial fibrillation (irregular heartbeat that lasts a short time and usually returns to normal). Current physician's orders included no CPR (cardiopulmonary resuscitation), dated [DATE]. An Indiana Physician Orders for Scope of Treatment (POST) form was completed on [DATE]. In the instructions, the form indicated if the patient lacked decisional capacity, the legal representative or a proxy may complete the POST on behalf of the patient. Section E indicated in order for the POST form to be effective the patient, legally appointed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was not started on a routine antipsychotic medication without indication for 1 of 5 residents reviewed for dementia care (Resident 82). Finding includes: During an observation, on 9/4/24 at 11:00, Resident 82 sat in a wheelchair in his room while his representative shaved him. He kept his eyes closed throughout the procedure and had to be roused for questions. During an observation, on 9/5/24 at 1:18 p.m., the resident sat outside the facility in a wheelchair with a visitor sitting at his side. During an observation, on 9/9/24 at 8:34 a.m., the resident sat in a wheelchair in his room and spoke about his wife. During an observation, on 9/9/24 at 1:54 p.m., the resident propelled himself in a wheelchair down the hallway using the siderails to pull himself and smiled as other residents, staff, and visitors talked to him. Resident 82's clinical record was reviewed on 9/6/24 at 8:23 a.m. He was admitted on [DATE]. Diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, facility failed to ensure residents received offered vaccinations available for 1 of 5 residents reviewed for immunizations (Resident 8). Findings include: Resident 8's clinical record was reviewed on 9/6/24 at 9:24 a.m. Diagnoses included dementia without behavioral disturbance, psychotic disturbance, anxiety, post- traumatic stress disorder, major depressive disorder and pneumonia. Resident 8 had received pneumococcal polysaccharide vaccine (PPSV) 23 on 7/12/16, and pneumococcal conjugate vaccine (PCV) 13 on 7/16/15. CDC recommendations indicated to give one dose of PCV 20 at least 5 years after the last pneumococcal vaccine dose. Resident 8 was educated on PCV 20 and consented for the vaccine on 5/18/24. A written interdisciplinary team (IDT) note on the vaccination consent form, dated 5/19/24, received from the DON on 9/9/24 at 10:00 a.m., indicated the resident was currently ill and he had a past reaction to the vaccine. At this time, Prevnar 20 was not required, and they would reassess in the future. During an interview, on 9/9/24 at 11:51…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.