Summers Healthcare Center: Pain Med Failure Before Death - WV
The inspection, triggered by a complaint, found that staff knew the ordered Oxycodone solution was unavailable and did not notify the physician who could have switched the prescription. The Director of Nursing later confirmed this directly to inspectors. The last documented dose of effective pain medication was administered at 1:32 in the afternoon on July 25, 2025. At 8:00 that evening, a nursing note recorded the resident as nonresponsive to both verbal and tactile stimuli. At 10:00 PM, a certified nursing assistant found the resident without respirations or pulse. The resident was pronounced dead.
CMS rated the violation as causing actual harm.
The nursing note from that evening documented that the Oxycodone was awaiting arrival from the pharmacy. That notation, in the record, captures the gap: staff knew the medication hadn't arrived. What the record does not show is anyone picking up the phone.
LPN #78, interviewed by inspectors on August 18 at 3:00 PM, was straightforward about what was in the emergency box. "We don't have liquid Oxycodone in the e-box for pain," the nurse said. "We do have liquid morphine available."
The Director of Nursing, interviewed the following morning, confirmed what should have happened. The physician should have been notified that the ordered medication was not in the emergency box. Had that call been made, the physician could have ordered the morphine instead. The DON said so plainly. The call was not made.
Emergency medication boxes exist precisely for situations where a resident cannot wait for a pharmacy delivery. The morphine was there. The authority to order it rested with a physician one phone call away. That call did not happen, and the resident's pain in the hours before death went unaddressed and, based on the record, unacknowledged by anyone with the ability to act.
The inspection report does not describe what the resident experienced during those hours. It does not need to. A person nonresponsive to touch by 8:00 PM, dead by 10:00 PM, whose last effective pain medication came eight and a half hours before death, is a person whose final hours are documented in the gap between a pharmacy delay and a phone call that was never made.
The same inspection identified a second resident whose care raised separate concerns about follow-through. Resident #73 had his left great toe amputated and was receiving pain medication every six hours. He told inspectors on August 11 that the medication was effective but that he sometimes experienced pain between doses, which he believed was phantom pain at the amputation site.
On August 17, he approached a nurse and reported something new: numbness and tingling in his left foot, and a separate and worsening problem with choking on food and drinks during meals. A nursing note documented the conversation. The physician was notified. A speech therapy evaluation was ordered for the choking. On the numbness and tingling, the physician said he would address it the following day when he came in.
The following day came. Resident #73 confirmed to inspectors on August 18 at 4:36 PM that the numbness and tingling persisted. He had not been seen by the physician.
On August 20, the Director of Nursing told inspectors there was no documentation the physician had evaluated or prescribed any treatment for the numbness and tingling after the resident first reported it three days earlier. The speech therapy referral for the choking had been ordered. The neurological symptom at the amputation site had not been addressed, and no record existed showing it had been examined.
Numbness and tingling following an amputation can indicate nerve damage, circulatory compromise, or other complications requiring evaluation. The inspection report does not characterize the medical significance of the delay. What it documents is that the symptom was reported, the physician was notified, the physician said he would look at it the next day, and three days later there was still no record of that ever happening.
Resident #73 knew something was wrong. He walked to the nurses' station himself to report it. He described the choking as becoming more of an issue. He was still waiting, three days later, for the physician to follow through on a commitment made the day the symptoms were first raised.
The two cases documented in this inspection share a structure. In both, the failure was not a lack of information. Staff knew the Oxycodone was unavailable. The physician knew about the numbness and tingling. The choking was documented and referred. The information existed. What did not follow was action: a phone call to a physician about a medication substitution, a physician visit that was promised and not completed, a follow-up that the record shows no evidence of occurring.
The Director of Nursing, in both cases, was the person who confirmed to inspectors what should have happened and did not. The DON confirmed the physician should have been called about the missing Oxycodone. The DON confirmed there was no documentation the physician had ever followed up on the amputation symptoms. Those are not the statements of someone unaware of the standards. They are the statements of someone describing, after the fact, a system that failed to meet them.
Summers Healthcare Center is located at 198 John Cook Nursing Home Road in Hinton, West Virginia. The complaint inspection was completed August 20, 2025.
The resident who died on July 25 is identified in the inspection record only by their status as a resident awaiting pain medication. Their name does not appear in the report. What appears is the timeline: 1:32 PM, last effective dose. 8:00 PM, nonresponsive. 10:00 PM, no pulse. And somewhere in the emergency box down the hall, a bottle of liquid morphine that was never ordered because no one called to ask.
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.
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 22, 2026 · Our methodology
SUMMERS HEALTHCARE CENTER in HINTON, WV was cited for violations during a health inspection on August 20, 2025.
The Director of Nursing later confirmed this directly to inspectors.
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.