A list of the most recent deficiencies for Summer Commons. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-15 | 2022-12-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-16 | 2022-12-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-16 | 2022-12-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-16 | 2022-12-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-16 | 2022-12-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-16 | 2022-12-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-16 | 2022-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-16 | 2022-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-16 | 2022-12-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-16 | 2022-12-23 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-11 | 2020-01-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-11 | 2020-01-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-13 | 2019-02-01 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-12-13 | 2019-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-13 | 2019-02-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-12-13 | 2019-02-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-12-13 | 2019-02-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-13 | 2019-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-13 | 2019-02-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Develop a communication plan. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Use approved construction type or materials. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Meet other general requirements. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
