Inspection Reports for Summit Commons Rehabilitation and Health Care Center
RI, 02906
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Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Jul 30, 2025
Visit Reason
A revisit survey and complaint survey were conducted at this nursing home on 07/30/2025 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance with several deficiencies (F 604, F 656, F 692, F 697, and F 698) but remained out of compliance with F 584 for failing to maintain a safe temperature range of 71 to 81 degrees Fahrenheit in multiple areas of the facility.
Complaint Details
The visit was complaint-related as it was a revisit survey and complaint survey (Event ID 1D273C-H1).
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe temperature range of 71 to 81 degrees Fahrenheit in the 1st floor main lobby and the 5th floor resident care unit, with temperatures reaching up to 84 F. | E |
Report Facts
Facility census: 128
Temperature readings: 84
Temperature readings: 83
Temperature readings: 83.4
Temperature readings: 82.4
Temperature readings: 82.6
Temperature range: 71
Temperature range: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during ambient temperature readings and acknowledged temperature issues. | |
| Administrator | Acknowledged temperature readings above allowed range during interview. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 14, 2025
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on March 13, 2025, and to verify the facility's compliance based on the submitted plan of correction and supporting documentation.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 11, 2025
Visit Reason
A revisit survey was conducted on April 11, 2025, to verify correction of all previous deficiencies cited on the March 13, 2025, Life Safety Code survey.
Findings
All deficiencies have been corrected at this time. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 113
Capacity: 165
Deficiencies: 9
Mar 13, 2025
Visit Reason
A recertification and complaint survey was conducted at Summit Commons Rehabilitation and Health Care Center from 3/10/2025 through 3/13/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to personal privacy/confidentiality of records, enteral nutrition and feeding tube management, dialysis care, physician supervision, nurse aide performance reviews, food safety and sanitation, resident records confidentiality, infection control, and life safety code compliance including fire safety and sprinkler system maintenance.
Severity Breakdown
Level 3: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to provide residents with the right to personal privacy and confidentiality of personal and medical records. | Level 3 |
| Facility failed to ensure residents fed through feeding tubes received appropriate treatment and services to prevent complications. | Level 3 |
| Facility failed to ensure residents requiring dialysis received services consistent with professional standards and care plans. | Level 3 |
| Facility failed to ensure physician supervision of medical care for residents with significant weight loss. | Level 3 |
| Facility failed to complete annual performance reviews for nurse aides. | Level 3 |
| Facility failed to ensure food safety requirements including proper labeling, dating, and storage of food items. | Level 3 |
| Facility failed to safeguard medical record information against loss, destruction, or unauthorized use. | Level 3 |
| Facility failed to maintain a quality assessment and assurance committee with required members and meeting attendance. | Level 3 |
| Facility failed to have annual State Fire Marshal inspection and failed to maintain fire alarm system and sprinkler system as required. | Level 3 |
Report Facts
Capacity: 165
Census: 113
Dates of survey: 4
Number of nurse aides missing annual performance reviews: 6
Weight loss percentage: 8.87
Weight loss percentage: 13.14
Fluid restriction order amount: 1500
Fluid restriction order amount: 1200
Dialysis frequency: 3
Dates of QAPI/QAA committee meetings: 5
Fire alarm quarterly maintenance reports missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to ongoing compliance responsibility and survey interviews | |
| Director of Nursing Services | Interviewed regarding fluid restriction and dialysis care | |
| Registered Nurse Staff B | RN | Interviewed regarding fluid restriction and dialysis care |
| Registered Nurse Staff A | RN | Interviewed regarding Enhanced Barrier Precautions and resident care |
| Licensed Practical Nurse Staff C | LPN | Interviewed regarding fluid restriction documentation |
| Assistant Director of Nursing | ADNS | Interviewed regarding dialysis resident care and documentation |
| Director of Nursing Services | DNS | Interviewed regarding resident records and infection control |
| Food Service Director | Interviewed regarding food safety and sanitation | |
| Regional Maintenance Director | Interviewed regarding fire safety and sprinkler system maintenance |
Inspection Report
Plan of Correction
Deficiencies: 0
May 7, 2024
Visit Reason
An off-site desk audit was conducted on May 7, 2024, to review all previous deficiencies cited on April 4, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 95
Capacity: 165
Deficiencies: 5
Apr 4, 2024
Visit Reason
A recertification survey and complaint investigation were conducted from 04/01/2024 through 04/04/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to laboratory services, food safety, infection prevention and control, and life safety code compliance. Specific issues included failure to obtain required lab tests, improper food storage and labeling, inadequate infection control practices for CPAP/BIPAP equipment, and failure to maintain fire alarm and sprinkler systems.
Complaint Details
The visit included a complaint investigation with ACTS Reference Numbers 94706, 94769, 94934, and 94935. The complaint investigation focused on laboratory services, food safety, infection control, and life safety code compliance.
Deficiencies (5)
| Description |
|---|
| Facility failed to obtain laboratory services to meet the needs of one resident for a valproic acid level lab test as ordered. |
| Facility failed to serve and store food under sanitary conditions, including cold holding temperatures and unlabeled food containers. |
| Facility failed to maintain an infection prevention and control program, including failure to clean CPAP/BIPAP equipment and masks for three residents. |
| Facility failed to ensure fire alarm system maintenance and testing in accordance with NFPA 101 Life Safety Code. |
| Facility failed to maintain sprinkler system and portable fire extinguishers per NFPA standards. |
Report Facts
Capacity: 165
Census: 95
Date of inspection: Apr 4, 2024
Number of residents impacted: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged lab was not obtained as ordered during surveyor interview |
| Director of Nursing Services | Director of Nursing | Acknowledged valproic acid lab was not obtained per physician's orders and lack of evidence of cleaning CPAP/BIPAP machines |
| Staff B | Dietary Aide | Observed serving food with improper hair restraint |
| Staff C | Dietary Aide | Observed without beard net while performing diet aide tasks |
| Staff D | Cook | Observed without beard net while preparing resident food |
| Staff E | Infection Preventionist | Interviewed regarding cleaning expectations for CPAP/BIPAP equipment |
| Maintenance Director | Unable to provide evidence of fire alarm and sprinkler system maintenance and testing |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 15, 2023
Visit Reason
An off-site desk audit was conducted on February 15, 2023 for all previous deficiencies cited on January 25, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 1
Jan 25, 2023
Visit Reason
A follow-up to a previous recertification survey was conducted to verify correction of prior deficiencies and to address a new deficiency related to resident records and identifiable information.
Findings
The facility failed to maintain complete and accurate medical records for residents, specifically regarding pressure injury evaluations and documentation. Deficiencies were found in the accuracy and completeness of wound evaluations and documentation for multiple residents.
Deficiencies (1)
| Description |
|---|
| Failure to maintain medical records that are complete and accurately documented for residents, including pressure injury evaluations. |
Report Facts
Date of survey completion: Jan 25, 2023
Number of residents reviewed for skin evaluations: 4
Dates of pressure injury evaluations with documentation issues: 1/10/2023, 1/17/2023, 1/24/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for ensuring compliance and unable to explain incomplete wound evaluation documentation | |
| Registered Nurse, Staff A | Acknowledged completing inaccurate pressure injury evaluations |
Inspection Report
Complaint Investigation
Deficiencies: 12
Dec 22, 2022
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Summit Commons Rehabilitation and Health Care Center from 12/20/2022 through 12/22/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey.
Findings
Deficiencies were cited related to freedom from abuse and neglect, accuracy of assessments, comprehensive care plans, professional standards of care, ADL care, skin integrity, nutrition and hydration, bedrails, drug regimen review, labeling and storage of drugs, infection prevention and control, and other regulatory requirements. The facility failed to ensure residents were free from abuse, assessments were accurate, care plans were implemented, and proper infection control measures were followed.
Complaint Details
The visit included a complaint investigation survey with ACTS Reference Numbers 88193, 88075, 88083, 88016. The complaint involved allegations of abuse and neglect, including resident-to-resident altercations and failure to protect residents from harm.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure residents were free from abuse for 1 of 5 residents reviewed, Resident ID #8. |
| Facility failed to accurately reflect resident status for wander guard use for 3 of 3 residents reviewed (Resident IDs 32, 37, 50). |
| Facility failed to develop and implement comprehensive person-centered care plans consistent with resident rights and needs for 4 residents relative to falls and abnormal involuntary movement scale (Residents 34, 35, 36). |
| Facility failed to ensure services met professional standards of quality for 2 of 3 residents related to wander guard use (Residents 32, 37). |
| Facility failed to provide care for dependent resident unable to carry out ADLs for 1 of 6 residents reviewed (Resident 62). |
| Facility failed to provide treatment and services to prevent pressure ulcers for 1 of 6 residents reviewed (Resident 37). |
| Facility failed to maintain acceptable nutritional status for 3 of 11 residents reviewed (Residents 37, 45, 73). |
| Facility failed to assess and monitor risk of entrapment from bed rails for 1 of 1 resident reviewed (Resident 17). |
| Facility failed to ensure monthly drug regimen review was completed for 1 of 9 residents reviewed (Resident 68). |
| Facility failed to store and label drugs and biologicals in accordance with accepted professional standards. |
| Facility failed to ensure food and drinks were palatable, attractive, and at safe and appetizing temperature for 1 of 18 residents reviewed (Resident 17). |
| Facility failed to ensure infection prevention and control program was effective to prevent transmission of communicable diseases and infections. |
Report Facts
Residents reviewed for abuse: 5
Residents reviewed for wander guard use: 3
Residents reviewed for care plan falls: 4
Residents reviewed for ADL care: 6
Residents reviewed for pressure ulcers: 6
Residents reviewed for nutrition: 11
Residents reviewed for bed rails: 1
Residents reviewed for drug regimen: 9
Residents reviewed for food and drink: 18
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