Summit Ridge Nursing: Resident Left Soaked - Douglas, WY
A resident at Summit Ridge Skilled Nursing & Rehabilitation had recently lost a leg above the knee. Unable to walk, unable to care for themselves, the resident needed two staff members and a mechanical lift just to get out of bed. On the afternoon of April 28, 2026, they were waiting for exactly that, lying in a wet brief and a soaking gown, the mattress soaked through beneath them.
At 1:56 p.m., the call light was on. Two minutes later, an unidentified staff member entered the room. The resident explained that two people were needed to provide care. The staff member left. The call light stayed on.
At 2:04 p.m., the same staff member returned, turned off the call light, and walked out again.
Nobody had come to help.
When a federal inspector spoke with the resident at 2:05 p.m., the resident said they had been waiting roughly 45 minutes for staff to return and provide incontinence care and take them to the shower. Then the resident said something that stopped the inspection in its tracks: it was not unusual to wait an hour or more for incontinence care. This was just how things went.
Eleven minutes later, three certified nursing assistants arrived with a mechanical lift. What they found when they pulled back the bedding told the story plainly. The resident's gown was soaking wet. The brief was soaking wet. The mattress underneath was wet. "Might as well take the gown off," the resident said. "It's soaking wet."
CNA #1 confirmed what was visible to everyone in the room.
The resident's care plan, dated April 13, 2026, had been explicit. Staff were to provide incontinence care after each incontinent episode. ADL needs were to be met each day. A cognitive evaluation two days before that showed the resident scored 13 out of 15 on a standard assessment, meaning they were fully cognitively intact. They knew exactly what was happening to them and exactly how long it had been happening.
A provider note from April 21 documented that the resident required assistance with personal care and could not perform daily living activities independently because of the amputation. This was not a borderline case or a matter of interpretation. The resident's dependence on staff was total and it was documented.
The facility's director of nursing was interviewed the following day. "Anyone who requires assistance receives the care they need," the DON said. Staff were expected to answer call lights and provide incontinence care at the time of need.
The inspection had taken place the day before.
The incontinence policy at Summit Ridge, last revised in April 2025, stated that all residents who are incontinent will receive appropriate treatment and services. The policy existed. The care plan existed. The documentation of the resident's condition and dependence existed. What did not exist, on the afternoon of April 28, was anyone willing to stay in the room long enough to help.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, and the deficiency affected one of four residents sampled for ADL care during the complaint inspection. The inspection was completed April 30, 2026.
What the inspection record cannot fully capture is what it means to be cognitively intact, to understand your situation completely, to press a call light and wait, and wait, and wait, in wet bedding you cannot change yourself, for staff who come to the door and leave. The resident at Summit Ridge knew what was happening. They had a word for it, too.
Not unusual.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summit Ridge Skilled Nursing & Rehabilitation from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Summit Ridge Skilled Nursing & Rehabilitation in Douglas, WY was cited for violations during a health inspection on April 30, 2026.
A resident at Summit Ridge Skilled Nursing & Rehabilitation had recently lost a leg above the knee.
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.