Focused Care at Summer Place

In the surveyor’s words

From the most serious findings on record at Focused Care at Summer Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 21, 2025

  Based on observation, interview, and record review, the facility failed to provide assistive devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A utilized a mechanical lift and had assistance from another staff member during a bed to wheelchair transfer on 05/05/25 which resulted in Resident #1 having complaint of pain to the right ankle. An x-ray was conducted on 05/05/25 with the results of evidence of acute fracture of the right distal tibia (bone in the lower leg). The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 05/05/25 and ended on 05/07/25. […]

• Actual harm, isolatedF689Oct 13, 2022

  Based on observation, interview, and record review, the facility failed ensure the environment was free of hazards to prevent accidents for 1 of 12 residents (Resident #1) reviewed for hazards and accidents. The facility failed to ensure Resident #1's wheelchair was secured properly in the facility's transport vehicle. Resulting in Resident #1 tipping over sideways, hitting his head, and sustaining a hematoma. This failure could place residents at risk for serious injury, decreased level of functioning, and diminished quality of life. […]

• Actual harm, isolatedF697Mar 30, 2022

  Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident #20) reviewed for pain management. The facility failed to identify Resident #20 had pain to her left hip. The facility failed to assess Resident #20 after her RP reported complaints of hip pain to a CNA (CNA E). CNA E failed to report Resident #20's RP concern of hip pain to nurse for resident to be assessed. Resident #20 was assessed two days later after RP reported hip pain again; NP ordered an xray and was diagnosed with a hip fracture. […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2025

  Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements.1. The facility failed to ensure spoiled strawberries were not stored in the walk-in cooler. 2. The facility failed to ensure raw meat was not stored on top of ready to eat green apples in the walk-in cooler. 3. The facility failed to ensure food items in the freezer #1, #2 and dry pantry were labeled, dated and sealed. […]

• No harm, potential for more than minimal, patternF755Aug 17, 2026

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 4 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for pharmaceutical services. The facility did not ensure accurate dispensing of medications for Resident #1, Resident #2, Resident #3, and Resident #4. This failure could place residents at risk of not receiving therapeutic levels of medications ordered by their physician. Findings included: Resident #1Record review of a face sheet dated 06/10/26 indicated Resident #1 was an [AGE] year-old female admitted on [DATE]. […]