Summer Commons

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF684Aug 27, 2025

  Based on record review and interviews, the facility failed to assess and monitor a resident after a fall and failed to follow their own Fall management and Neurological evaluation policies and procedures by obtaining neurological assessments for residents who had unwitnessed falls for 3 of 6 residents reviewed for falls. (Resident #9, #23, #71) The facilities Falls Management Policy last updated 2/2025 states under procedure; A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not. Complete Post Fall Observation Tool, following a fall, to identify if the cause of the fall is related to mental status changes, physical limitations or environment factors. […]

• No harm, potential for more than minimal, patternF759Nov 16, 2022

  Based on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 33 opportunities. The medication error rate was 6.06% Findings: The facility Eye Drop Administration Policy and Procedure, effective 5/1/2018 instructs nursing to put on examination gloves, with a gloved finger, gently pull down lower eye lid to form pouch, while instructing resident to look up. Place other hand against the resident's forehead to steady. […]

• No harm, potential for more than minimal, patternF761Nov 16, 2022

  Based on observations and interviews, the facility failed to ensure that medications were stored properly by having unattended medication cards on top of the cart allowing residents and unauthorized persons access to them on 1 of 3 days of survey. In addition, the facility failed to ensure expired medications were removed from the supply available for use in 2 of 2 medication rooms (July and August). Findings: 1. On 11/15/22 at 8:36 a.m., during the medication pass observations, the Registered Nurse (RN) locked the medication cart leaving 3 blister packs of medication on top of the cart while she walked away and entered the medication room. The medications were unsecured for approx. 2 minutes. […]

• No harm, potential for more than minimal, patternF812Nov 16, 2022

  Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was labeled and dated in the refrigerator for 2 of 3 days of survey. In addition, the facility failed to monitor refrigerator/freezer temperatures and sanitizer bucket part per million (ppm) daily. Findings: 1. On 11/14/22 at 9:20 a.m., during the initial tour of the kitchen with the Dietician and the Food Service Director (FSD), the following was observed: A moderate amount of debris all over the floor, a heavy amount of dirt and debris on the bottom shelf of the food prep stand, two ceiling vents coated with dust and two ceiling vents with dust hanging from the vents. […]

• No harm, potential for more than minimal, patternF880Nov 16, 2022

  Based on observations, interviews and record reviews the facility failed to maintain an Infection Control Program designed to help prevent the development of infection related to oxygen tubing, bed pans and commodes for 3 of 3 days of survey and failed to prevent the possible transmissions of infections by handling medications and administering injection and eye drops with ungloved hands during medication administration for 2 of 2 medication pass observations. Findings: 1. On 11/14/22 at 11:51 a.m., 11/15/22 at 8:01 a.m., and 11/16/22 at 8:33 a.m., observations of room [ROOM NUMBER] to have Oxygen tubing and nasal cannula lying on the floor, a bed pan stored upside down on the toilet and a seat cushion stored between the toilet and the wall. 2. […]