Inspection Reports for Summit Commons Rehabilitation and Health Care Center

The complaint investigation was triggered by allegations that a resident was forcibly medicated against their will, concerns about inadequate weight monitoring for a resident with significant weight gain, and failure to provide dietary consultations for multiple residents. The complaint was submitted to the Rhode Island Department of Health on 9/30/2025 and 12/6/2025.

The facility failed to honor a resident's right to refuse medications, failed to monitor a resident's weight adequately, and failed to provide dietary consultations by a qualified dietitian for multiple residents. Several deficiencies were noted with minimal harm potential affecting few to many residents.

The complaint investigation was substantiated based on the finding that Resident ID #1 tested positive for Legionella pneumonia and the facility failed to implement required water management and testing protocols.

The facility failed to maintain an infection prevention and control program, specifically failing to implement a water management program based on CDC standards, resulting in Legionella bacteria presence in multiple water samples and an infection in one resident. The facility did not perform required quarterly testing or document mitigation steps such as flushing and disinfection, and failed to conduct annual water program assessments with a qualified contractor.

The visit was complaint-related as it was a revisit survey and complaint survey (Event ID 1D273C-H1).

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.

The visit was complaint-related based on multiple community reported complaints received by the Rhode Island Department of Health alleging lack of air conditioning, improper use of restraints, inadequate nutrition care, pain management failures, and poor communication with dialysis providers.

The facility failed to maintain safe ambient temperatures, resulting in residents experiencing excessive heat. Physical restraints were improperly used on a cognitively impaired resident without physician orders. A resident experienced significant weight loss without a comprehensive care plan or proper communication with the dialysis center. Pain management was inadequate due to a discontinued medication order, leading to emergency hospital transfer. Communication failures with the dialysis center regarding resident conditions were also noted.

The complaint investigation was substantiated based on a community complaint submitted on 5/13/2025 alleging a Nursing Assistant was attempting to shower the resident when the shower chair broke and the resident fell. The facility reported incident on 5/8/2025 confirmed the fall and injury.

The facility failed to ensure the resident's environment was free from accident hazards, resulting in a fall with injury when a shower chair broke while being pulled over an incline. The resident sustained fractured ribs and was admitted to the Trauma Intensive Care Unit. Staff interviews and observations confirmed the incident and identified improper use of the shower chair on an incline contrary to manufacturer instructions.

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.

The facility was found deficient in multiple areas including failure to protect resident privacy, improper feeding tube care, inadequate dialysis care and communication, lack of physician notification for significant weight loss, missing annual nurse aide performance reviews, improper food labeling and storage, inaccurate medical record documentation for enhanced barrier precautions, and failure to maintain a proper infection prevention and control program.

The facility failed to ensure that one resident did not receive significant medication errors. The resident was administered both 100 MCG and 87.5 MCG doses of Levothyroxine simultaneously for five consecutive days, resulting in a total dose of 187.5 MCG instead of the ordered 87.5 MCG. This medication error was not identified by the facility until the surveyor brought it to their attention.

The complaint investigation found that the facility did not ensure proper administration of prescribed medication for Resident ID #1, with missed doses due to pharmacy approval delays and resident refusals. The provider was not notified as expected.

The facility failed to ensure that Resident ID #1 received prescribed Nimodipine medication as ordered, missing multiple doses due to pharmacy delivery delays and resident refusals. Documentation was lacking to show that the provider was notified of these missed doses.

The complaint was submitted to the Rhode Island Department of Health on 12/26/2024 alleging numerous medication errors involving several residents, including insulin.

The facility failed to ensure residents received treatment and care according to professional standards, including improper insulin administration methods, administration of insulin without a physician's order, failure to document provider notifications for high blood sugar readings, and incomplete facility-wide assessments related to staffing.

The complaint was an anonymous community report submitted to the Rhode Island Department of Health on 10/8/2024 alleging that Resident ID #1 eloped on 10/7/2024 and that management delayed disclosure and discouraged filing a complaint.

The facility failed to ensure adequate supervision to prevent elopement of a cognitively impaired resident, Resident ID #1, who left the facility unnoticed for approximately 6 hours and traveled about 13.2 miles before being found by police. The facility did not follow its elopement policies, failed to obtain a Leave of Absence order, delayed notification of the police, and did not implement safety measures upon the resident's return, placing the resident at immediate risk of harm.

The complaint alleged that Resident ID #1 reported the facility was not adhering to the medical treatment plan related to bilateral lower extremity wounds. The investigation focused on wound care deficiencies for Resident ID #2, including burns and pressure ulcers.

The facility failed to provide appropriate wound care and treatment according to professional standards for Resident ID #2, including failure to follow burn clinic and wound physician recommendations, incomplete and inaccurate skin assessments, and lack of treatment orders for burns and pressure injuries. These deficiencies were observed through record reviews, staff interviews, and surveyor observations.

Complaint was substantiated based on record review and staff interviews confirming that Resident ID #1 received an accidental dose of Suboxone not ordered for them.

The facility failed to keep residents free from significant medication errors for 1 of 3 residents reviewed. Resident ID #1 was administered Suboxone, a medication not ordered for them, due to a failure by Staff A to properly identify the resident before medication administration.

The facility failed to obtain timely laboratory tests for a resident on Depakote medication, failed to maintain sanitary food storage and serving conditions including improper food labeling and inadequate temperature control, and did not ensure proper cleaning and disinfection of CPAP/BIPAP respiratory equipment for multiple residents, indicating lapses in infection prevention and control.

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 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.

The complaint alleged that the resident was admitted to the hospital following an unresponsive episode possibly due to a medication error. The investigation confirmed that the resident received insulin outside of ordered parameters and that Glucagon was improperly administered due to lack of nurse competency, resulting in critical hypoglycemia and hospital admission.

The facility failed to ensure licensed nurses had the appropriate competencies to administer Glucagon correctly and to follow insulin administration parameters, resulting in a resident experiencing a critically low blood sugar, requiring emergency interventions including Glucagon administration, oxygen, intravenous Dextrose, and hospital admission.

Complaint reported on 2024-03-06 alleged Resident ID #1 was discharged with another resident's medications and was not instructed on medication use, resulting in the resident taking incorrect medications for one week, causing confusion, falls, and injury.

The facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications and did not complete a discharge summary for Resident ID #1. Resident ID #1 was discharged with Resident ID #2's medications, leading to medication errors, confusion, falls, and injury. Facility staff acknowledged these failures during interviews.

The complaint was substantiated based on surveyor observation, record review, and staff interviews confirming the wheelchair was broken and used for Resident ID #1 during transport to an outpatient appointment.

The facility failed to maintain patient care equipment in safe operating condition, specifically a wheelchair with a broken right-side wheel lock brake and damaged arm rests. Staff acknowledged the wheelchair was used despite its condition and failed to report or remove it from service promptly.

The complaint was substantiated based on the findings of pest infestations including bedbugs and roaches, confirmed during the survey and interviews with facility staff.

The facility failed to maintain an effective pest control program from 2023-04-27 to 2023-07-13 due to non-payment to the vendor, resulting in a fruit fly and roach infestation in the kitchen and dishwashing floor drains, and a bed bug problem in a resident room on the second floor. Interventions including chemical treatments were implemented between 2023-07-14 and 2023-07-17 to address the infestations.

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.

The visit was complaint-related, triggered by allegations of resident abuse, failure to follow care plans, inaccurate assessments, medication errors, infection control breaches, and other quality of care concerns. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to prevent resident abuse, inaccurate resident assessments, failure to follow care plans, inadequate medication management, improper infection control practices, failure to maintain medical records accurately, and failure to provide appropriate care and services such as nutrition, hygiene, and pressure ulcer prevention.

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 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.