The patient received their last documented pain medication at 1:32 PM on July 25. A physician ordered liquid oxycodone at 5:18 PM that evening, but the medication was waiting for delivery from the pharmacy. By 8:00 PM, nursing notes showed the resident had become nonresponsive to verbal and physical contact and couldn't take medications. A certified nursing assistant found the patient without breathing or pulse at 10:00 PM. The resident was pronounced dead at that time.
Federal inspectors found that Summers Healthcare Center had liquid morphine available in their emergency medication box throughout the evening. Staff never contacted the physician to request an alternative pain management order.
LPN #78 confirmed the facility's medication limitations during an August 18 interview. "We don't have liquid Oxycodone in the e-box for pain, we do have liquid morphine available," the nurse told inspectors.
The Director of Nursing acknowledged the breakdown in communication when questioned the following day. She confirmed that staff should have notified the physician when the ordered oxycodone solution wasn't available. The physician could have prescribed morphine instead, which was sitting unused in the emergency supply.
The inspection, conducted August 20 following a complaint, revealed a pattern of inadequate pain management affecting multiple residents. Federal investigators classified the violations as causing "actual harm" to some patients.
Another resident, identified as #73, described receiving pain medications every six hours following amputation of his left big toe. He told inspectors on August 11 that the scheduled medications were effective but he sometimes experienced pain between doses. He believed he was suffering phantom pain at the amputation site.
Six days later, the same resident approached nursing staff with new symptoms. A nursing note from August 17 at 2:13 PM documented his complaints: "Resident approached this nurse and stated he is having some numbness and tingling in his left foot. He also states he has been getting strangled on food and drink during meals. He states that it does not happen during every meal, but it is becoming more of an issue for him."
Staff notified the physician about these concerning symptoms. The doctor ordered speech therapy evaluation and treatment for the swallowing problems. According to the nursing note, the physician said "he will address the numbness and tingling tomorrow when he comes in."
Tomorrow never came.
When inspectors interviewed the resident the next day, August 18 at 4:36 PM, he confirmed he was still experiencing numbness and tingling at his amputation site. He stated he had not been seen by the physician that day, despite the previous day's promise.
The Director of Nursing admitted to inspectors on August 20 that no documentation existed showing the physician had evaluated or prescribed treatment for the resident's numbness and tingling. Three days had passed since the resident first reported the symptoms.
The violations occurred under federal regulations requiring nursing homes to provide appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facilities must ensure that residents receive treatment for pain and that physicians respond promptly to changes in residents' conditions.
For the resident who died, the failure was immediate and fatal. Staff documented that oxycodone was "awaiting arrival from the pharmacy" at 5:18 PM but took no action to secure alternative pain relief. The resident's condition deteriorated over the following hours without intervention.
The facility's emergency medication supply contained liquid morphine specifically for situations when ordered medications aren't immediately available. Staff knew about this alternative but never used it. The morphine sat in the emergency box while the resident spent their final hours without pain relief.
For Resident #73, the breakdown was slower but equally concerning. The resident specifically described his symptoms to nursing staff and was promised physician evaluation within 24 hours. The doctor's failure to follow through left the resident with untreated neurological symptoms that could indicate serious complications.
Phantom pain after amputation affects up to 80 percent of patients and can be severe enough to interfere with sleep, daily activities, and rehabilitation. Numbness and tingling at amputation sites can signal nerve damage, infection, or circulation problems requiring immediate medical attention.
The inspection findings highlight systemic communication failures between nursing staff and physicians at Summers Healthcare Center. In both cases, residents' medical needs went unmet despite available treatments and clear protocols for physician notification.
The facility's 31-page inspection report documented additional deficiencies beyond pain management failures. The complaint-driven investigation examined multiple aspects of resident care and safety protocols.
Summers Healthcare Center operates as a 120-bed skilled nursing facility in Hinton, serving residents requiring long-term care and short-term rehabilitation services. The facility has faced previous federal inspections and enforcement actions for various violations of Medicare and Medicaid participation requirements.
The latest violations occurred during a period when healthcare facilities nationwide have faced scrutiny for inadequate pain management and delayed medical response. Federal regulators have emphasized that nursing homes must maintain 24-hour physician availability and emergency medication supplies to prevent exactly these types of failures.
The resident who died on July 25 spent their final conscious hours in pain that could have been relieved with a simple phone call to their physician. The morphine that could have provided comfort remained unused in the emergency supply while staff waited for a pharmacy delivery that came too late.
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.