Summers Healthcare Center: NPO Diet Failure - WV
The incident was serious enough that federal inspectors classified it as causing actual harm. It was serious enough to affect more than one resident. And when inspectors arrived and asked what the facility had done in response, the administrator said she wasn't sure until she pulled up the Facility Reported Incident herself.
NPO is one of the clearest instructions in medicine. It exists because swallowing food or liquid can cause aspiration, choking, or surgical complications that kill people. A resident placed on NPO status is on it for a reason.
The inspection, completed August 20, 2025, stemmed from a complaint. Inspectors found that Resident 61 was on NPO status when a meal appeared in front of them. Whether Resident 61 actually ate it, the facility could not say with certainty. Investigators reached the conclusion that a meal was served but could not solidly conclude the resident consumed it. That ambiguity did not soften the finding. The harm rating was actual, not potential.
What happened after was its own problem.
The administrator told inspectors there was no follow-up education for other NPO residents after the incident. None. A resident on a strict medical dietary restriction received food they weren't supposed to have, and the people responsible for the other residents on similar restrictions were not pulled together, not retrained, not told what went wrong or how to prevent it from happening again.
By August 12, 2025, the facility had brought the matter before its Quality Assurance and Performance Improvement committee. The committee's response was to recommend that NPO residents be grouped with other NPO residents, or moved to eat with residents who take their meals in the dining room rather than in their rooms. A seating arrangement. That was the plan.
There was no education outlined in the QAPI plan for residents with modified diets. Not for NPO residents specifically. Not for residents on thickened liquids or texture-modified foods. The committee reviewed the incident and produced a logistical recommendation without addressing whether staff understood the medical stakes of the restrictions they were responsible for enforcing.
Modified diets in a nursing home are not a preference. They are a clinical order. A resident on a pureed diet has a swallowing disorder that makes regular food a choking hazard. A resident on thickened liquids is at risk of aspirating thin fluids into their lungs. A resident on NPO has been told, by a physician, that their body cannot safely handle anything by mouth at that time. The consequences of getting it wrong range from aspiration pneumonia to death.
Summers Healthcare Center sits on John Cook Nursing Home Road in Hinton, a small city in Summers County in southern West Virginia. The facility's Medicare identification number is 515170.
The inspection report does not say who brought the meal to Resident 61. It does not say whether anyone was disciplined. It does not say how long the resident had been on NPO status, what medical condition required it, or how the meal ended up in front of them in the first place. What it says is that actual harm occurred, that the administrator was uncertain about the facility's own response until she looked it up, and that no education for staff caring for NPO residents was part of the plan going forward.
The QAPI committee met. A recommendation was made. And somewhere in Summers Healthcare Center, other residents remain on NPO status, on modified diets, dependent on staff who were never formally told what happened or why it mattered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summers Healthcare Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
SUMMERS HEALTHCARE CENTER in HINTON, WV was cited for violations during a health inspection on August 20, 2025.
The incident was serious enough that federal inspectors classified it as causing actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.