Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summerhill Elderliving Home & Care during CMS and state inspections, most recent first.
Kitchen sanitation, hand hygiene, and beard guard failures: Surveyors observed heavily soiled kitchen equipment and surfaces, including dirty ovens, fryers, stove areas, walk-in cooler/freezer debris, cracked flooring, and splattered walls and ceilings, with cleaning documentation missing for multiple areas. A DA was seen touching clean dishes after handling dirty dishes without washing hands, and a DA and Cook serving on the tray line had beards without beard guards.
The facility failed to maintain an effective pest control program, with repeated complaints of roaches, ants, silverfish, flies, and water bugs in resident rooms and reports of a roach in a resident’s food and bed. Surveyors also observed signs of a roach infestation in the kitchen, including small dark specks at the entrance column and numerous cockroaches scattering when a wheeled sanitizer bucket was moved near the 3-comp sink. The CDM and Administrator acknowledged ongoing pest issues and recent pest treatments.
Failure to Provide Transfer and Bed-Hold Notices: The facility did not provide written transfer notices or bed-hold information to residents or their RRs after emergent hospital transfers for four residents. Records showed missing eInteract transfer forms and no documentation that the required notice, appeal rights, or bed-hold details were sent with the resident, communicated to the hospital, or provided to the RP/RR. The DON, Administrator, and FC confirmed the notices were not completed or sent.
Failure to complete and transmit required MDS assessments for two residents was identified. One resident was discharged, but no discharge MDS was entered, completed, or sent to CMS, and another resident had a Death in Facility assessment completed in the EMR but it was never transmitted. The CCRC acknowledged both omissions, and the Administrator stated the facility follows the RAI Manual for MDS timing requirements.
Inaccurate PASRR Level II Status on MDS: A resident with dx of major depressive disorder, anxiety disorder, and bipolar disorder had a PASRR Level II indicating SMI, but the annual MDS incorrectly marked the PASRR Level II question as No. The SSD and MDSC both confirmed the resident should have been coded Yes, and the MDSC stated PASRR status is usually already filled out or obtained from SS.
Untrimmed and Unclean Fingernails: A resident with impaired decision-making and dependence for personal hygiene was observed with fingernails that were excessively long and had brown debris underneath them. A CNA, an LPN, and the DON confirmed the nails needed trimming and cleaning during ADL care, and the facility policy required daily cleaning and regular trimming of nails.
A resident with Parkinson's and dementia was physically abused by a CNA, who grabbed her hand tightly and took her call light, causing bruising. The resident, assessed as cognitively intact, consistently reported the incident, which was confirmed by an investigation. The facility's abuse prevention policy was not effectively implemented, leading to the CNA's termination.
A resident fell and was injured when a CNA provided ADL care alone, contrary to the care plan requiring two staff members. Another resident received the wrong medications due to an LPN's identification error, leading to hospital admission for observation. Both incidents resulted in harm and were confirmed by facility investigations.
A resident, who was cognitively impaired and dependent on staff for ADL care, fell from the bed and sustained a laceration to the forehead due to unsecured bed bolsters and inadequate staffing. The resident's care plan required two staff members for assistance, but a CNA provided care alone, leading to the accident. The resident was hospitalized and received sutures for the injury.
A resident received the wrong medications due to an LPN's error, and the facility failed to promptly notify the physician or nurse practitioner as required by policy. The error was identified, but there was a delay in notifying the RN Supervisor and no immediate notification to the physician, leading to the resident being hospitalized for monitoring.
A facility failed to report an abuse allegation involving a resident with bruising to law enforcement, as required by their policy. The resident, with multiple diagnoses including dementia, alleged that a CNA caused the bruising. Although the physician, responsible party, and ombudsman were notified, law enforcement was not informed until after surveyor inquiry.
A facility failed to update a resident's care plan to include actual skin impairment, specifically bruising on the right hand, despite a policy requiring revisions as conditions change. The bruising was identified following an alleged staff-to-resident abuse incident. The MDS Coordinator confirmed that the care plan should have been updated, with responsibility lying with the treatment nurse or RN supervisor.
A medication administration error occurred when an LPN administered the wrong medications to a resident after misidentifying him. The resident was hospitalized for monitoring. The LPN documented administering medications after being relieved of duties, despite the resident being at the hospital. This discrepancy highlights a failure to meet professional standards of quality in medication administration and documentation.
A resident in an LTC facility was mistakenly given another resident's medications by an LPN who failed to verify the resident's identity properly. The error led to the resident being hospitalized for observation after experiencing a vasovagal syncope episode. The Medical Director confirmed the error was significant but not life-threatening.
A resident was found with topical medications at their bedside without an assessment or physician orders for self-administration, contrary to facility policy. Staff interviews confirmed that medications should not be left unsecured without proper authorization, highlighting a lapse in adherence to medication management protocols.
Kitchen sanitation, hand hygiene, and beard guard failures
Penalty
Summary
The facility failed to ensure kitchen equipment, floors, walls, and ceiling surfaces were clean and in good repair, and failed to ensure beard guards were worn and hand hygiene was performed during dishwashing. During kitchen observations, the walk-in refrigerator had dried spillage and trash debris along the walls behind shelves, and a long crack across the concrete floor. The walk-in freezer contained numerous stacks of food boxes, some crushed so the food product was exposed, and food debris was present throughout the freezer. The convection ovens, stove top, burners, fryer wells, fryer cabinets, and surrounding areas were heavily soiled with baked-on grease, charred food debris, and dried spillage. The walls and baseboards behind the beverage station and trash barrel had dried splatters, the ceiling throughout the kitchen had dried splatters, and door frames had worn paint and exposed wood. The Certified Dietary Manager’s kitchen observation from 12/04/25 also documented dirty ovens, greasy fryer and stove areas, a dirty floor bin, a walk-in in total disarray, and a cracked floor, with no cleaning schedule followed for kitchen and food service equipment. During dishwashing, a Dietary Aide was observed touching clean dishes without washing hands after touching dirty dishes while operating the dish machine. The Dietary Supervisor stated the aide should have washed hands before touching clean dishes. During lunch tray line service, a Dietary Aide and a Cook had beards and were not wearing beard guards. The Dietary Supervisor stated men with beards should wear beard guards and said beard guards were out at the time. The facility policy required the food service area to be maintained in a clean and sanitary manner and required utensils, counters, shelves, and equipment to be kept clean and in good repair, free from breaks, corrosion, open seams, cracks, and chipped areas. The hand hygiene policy stated hand hygiene was the primary means to prevent the spread of infections and that personnel shall be trained and regularly in-serviced on its importance.
Failed Pest Control Program Allowed Roach Infestation in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent an infestation in the kitchen and resident rooms. The grievance log documented repeated complaints about pests, including water bugs, roaches, ants, silverfish, and flies in resident rooms, a roach found in a resident’s food, a roach found in a resident’s bed, and ongoing reports that rooms still had roaches. The facility’s pest control receipts showed multiple cockroach treatments over several months, including treatments to the exterior, entry points, patient/guest rooms, and the kitchen area. During observation and interviews, surveyors found signs of a roach infestation in the kitchen. The top of the column at the entrance door had a collection of small dark specks resembling a pepper appearance, and when the Dietary Supervisor moved a wheeled sanitizer bucket next to the three-compartment sink, a large collection of small cockroaches scattered in all directions. The same bucket was moved again two days later and more small cockroaches scattered. The CDM stated the kitchen had been treated with a roach bomb in late December 2025, and the Administrator later observed several dead roaches in and around the chemical bucket and the speck-like collection at the entrance column. The facility policy stated it maintains an ongoing pest control program to keep the building free of insects and rodents.
Failure to Provide Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer notices and bed-hold information to residents and their resident representatives following emergent hospital transfers for four residents reviewed. The record review showed that for R4, who was admitted with multiple conditions and was transported to the hospital by EMT on 01/06/26, there was no eInteract Transfer Form completed and no documentation that R4 or the resident representative received the transfer notice or bed-hold policy, or that the information was conveyed to the hospital at the time of transfer. The Financial Coordinator confirmed he did not send the notice of transfer form or bed-hold policy to the hospital, resident, or responsible party, and the DON confirmed the nurse did not complete or send the transfer form and did not call report to the hospital. For R3, who had diagnoses including diabetes mellitus, end stage renal disease, heart failure, anxiety disorder, COPD, bipolar disorder, and dialysis dependence, the record showed transfers to the ER on 11/14/25 and 11/26/25. R3’s five-day MDS indicated a BIMS score of 11 out of 15, reflecting moderately impaired cognition. The chart contained no documentation that the bed-hold policy was provided to the resident representative at the time of transfer, and no eInteract Transfer Form was completed for the 11/26/25 transfer. The Administrator confirmed the transfer form could not be found and stated the FC had not been sending bed-hold notifications for Medicaid residents; the DON also confirmed there was no written notice of transfer, and the FC stated the representative would not have been aware of the bed-hold process because notification was not sent. For R11, who had chronic respiratory failure, COPD, heart failure, diabetes mellitus, dialysis dependence, anxiety disorder, end stage renal disease, and dementia, the record showed ER transfers from dialysis for shortness of breath on 12/08/25 and 12/27/25. R11’s annual MDS indicated severe cognitive impairment. There was no documentation that a written transfer notice or bed-hold information was provided to the resident representative for either transfer, and the FC stated bed-hold notifications had not been sent. For R141, who had dementia, influenza, and repeated falls, the record showed transfer to the hospital for aggressive behavior and possible infection, and the hospital transfer note documented that the responsible party was notified that the resident had left the building. However, there was no documentation that a written transfer notice or bed-hold information was provided to the responsible party at the time of transfer.
Failure to Complete and Transmit Required MDS Assessments
Penalty
Summary
The facility failed to encode and transmit MDS assessments to the CMS system for two residents out of 32 sampled residents. For one resident, the EMR progress notes showed discharge from the facility on 08/18/25, but the MDS tab contained no discharge MDS assessment that was entered, completed, or transmitted to CMS. For another resident, the EMR MDS tab showed a Death in Facility assessment with an ARD of 08/25 that had been entered and completed, but it was not transmitted to the CMS site. During interview, the Corporate Clinical Reimbursement Coordinator acknowledged that the discharge MDS for the first resident was not entered, completed, or transmitted, and acknowledged that the Death in Facility assessment for the second resident was completed but never transmitted. The Administrator stated the facility follows the RAI Manual for MDS completion and transmission timing. The RAI Manual states a discharge MDS must be completed within 14 days after discharge and submitted within 14 days after completion, and a death in facility tracking record must be completed within 7 days after death and submitted within 14 days after death.
Inaccurate PASRR Level II Status on MDS
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to submit an accurate MDS for one resident by incorrectly marking the PASRR Level II status as No. The resident was admitted with diagnoses of major depressive disorder, anxiety disorder, and bipolar disorder. The resident’s Treatment Service: PASRR Level II documented Serious Mental Illness with diagnoses of bipolar disorder, generalized anxiety disorder, and major depressive disorder, yet the annual MDS with an ARD of 06/25/25 showed a BIMS score of 14 out of 15 and indicated the resident was cognitively intact while answering No to whether the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During interviews, the Social Services Director reviewed the record and confirmed the resident did have a PASRR II and that the MDS should have been marked Yes. The MDS Coordinator also reviewed the annual MDS, confirmed she completed Section A including PASRR Level II status, and stated PASRR Level II status is usually already filled out; if not, she calls social services and would not know where to look for it in the computer. After contacting social services, the MDS Coordinator confirmed the resident had a PASRR Level II and the MDS should have been marked Yes. The facility policy stated the Level II evaluation report must be used when conducting assessments, developing the care plan, and during transitions of care, and the RAI Manual stated information obtained should be validated for accuracy by the IDT completing the assessment.
Untrimmed and Unclean Fingernails
Penalty
Summary
The facility failed to ensure that Resident 12’s fingernails were kept clean and properly trimmed. The resident was admitted on [DATE] and had a care plan entry dated 04/21/22 directing staff to observe for the need to trim fingernails and toenails during bath or shower time and to notify the nurse if these items needed to be completed. The quarterly MDS with an ARD of 11/12/25 indicated the resident had moderately impaired decision-making, one-sided upper extremity functional limitation, and was dependent for personal hygiene. During observations on 01/20/26 and 01/22/26, Resident 12 was seen with fingernails approximately half an inch long on the right hand and over one inch long on the left hand, with a thick brown substance or brown substance underneath the nails. A CNA and an LPN both confirmed the length and condition of the fingernails and stated they should be trimmed for hygiene, sanitation, and to prevent scratching. The DON also confirmed the nails should be trimmed and cleaned daily during ADL care, and that the resident should be care planned for refusal if she refused nail care. The facility policy titled Care of Fingernails/Toenails stated nail care includes daily cleaning and regular trimming, and that proper nail care helps prevent skin problems and accidental scratching.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with a diagnosis of Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia, who was assessed as cognitively intact. On the night of the incident, the resident reported that the CNA grabbed her hand tightly and took her call light, resulting in bruises and discoloration on the first three fingers of her right hand. The resident consistently reported the incident to multiple staff members, and the investigation confirmed the occurrence of the abuse. The facility's Abuse Prohibition Policy and Procedures, which were in place to prevent such incidents, were not effectively implemented in this case. The policy defined abuse as the willful infliction of injury or punishment with resulting physical harm or pain. Despite the policy, the CNA's actions led to physical harm to the resident. The facility's documentation and investigation revealed that the CNA was removed from the schedule and subsequently terminated following the confirmation of the abuse.
Staffing and Medication Errors Lead to Resident Harm
Penalty
Summary
The facility failed to provide the appropriate number of staff for Activities of Daily Living (ADL) care as care planned for a resident, resulting in actual harm. The resident, who had impaired cognition, a self-care deficit, and was at risk for falls, required total assistance from two staff members to turn and reposition in bed. However, on the day of the incident, a CNA provided care alone, leading to the resident falling from the bed and sustaining a laceration to the forehead. The resident was sent to the hospital for evaluation and received sutures for the injury. In another incident, the facility failed to administer medications as care planned and ordered for a resident with multiple diagnoses, including hemiplegia, aphasia, and cardiovascular issues. An LPN administered the wrong medications to the resident after incorrectly identifying him, leading to the resident being admitted to the hospital for observation due to potential side effects from the medication error. The LPN had asked the resident if his name was another resident's last name, and the resident, who was known to joke, confirmed the incorrect name. Both incidents highlight deficiencies in following care plans and ensuring proper medication administration, resulting in harm to the residents involved. The facility's investigation confirmed these failures, with staff acknowledging the errors and the Director of Nursing confirming the deviations from the care plans.
Failure to Secure Bed Bolsters and Provide Adequate Staffing Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that bed bolsters were secured and that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, leading to an accident involving a resident. The resident, who was cognitively impaired and dependent on staff for ADL care, including bed mobility, fell from the bed and sustained a laceration to the forehead. The resident's care plan required total assistance from two staff members for turning and repositioning in bed, but a Certified Nursing Assistant (CNA) provided care alone, contrary to the care plan. During the incident, the CNA attempted to change the resident, who had a bowel movement, by positioning her on her side. However, the bolster, which was not secured to the bed, slid off, causing the resident to fall to the floor. The resident was found with a cut above the right eyebrow and a scrape to the right knee, with noticeable bleeding. The incident was reported, and the resident was sent to the hospital for evaluation, where she received sutures for the laceration.
Failure to Promptly Notify Physician of Medication Error
Penalty
Summary
The facility failed to ensure timely notification of a significant medication error to the physician or nurse practitioner for a resident. On 12/19/2024, an LPN administered the wrong medications to a resident, who was cognitively intact with a BIMS score of 15 out of 15. The error involved administering 14 medications intended for another resident. The LPN identified the error at 10:15 am but did not notify the RN Supervisor until 11:00 am, and there was no evidence that the resident's physician or nurse practitioner was notified immediately. The facility's policy on Adverse Consequences and Medication Errors required immediate action and prompt notification of the attending physician in the event of a significant medication error. The Medical Director confirmed that the LPN should have notified him or the nurse practitioner right away, considering five to ten minutes as prompt notification. The delay in notification was not in compliance with the facility's policy, and the resident was sent to the hospital for monitoring of potential side effects.
Failure to Report Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse to law enforcement as required by their Abuse Prohibition Policy and Procedures. The policy mandates that any reasonable suspicion of a crime be reported to the State Agency and law enforcement. An incident involving a resident, who had been admitted with diagnoses including Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia, was documented. The incident report noted bruising on the resident's right hand, which was alleged to have been caused by a staff member. Although the physician, responsible party, and ombudsman were notified, law enforcement was not informed of the incident. The Director of Nursing confirmed during an interview that law enforcement was not notified. The Administrator explained that the decision not to report to the police was based on the belief that the incident did not result in serious bodily injury. However, after the surveyor's inquiry, the facility contacted law enforcement, and the incident was reported as Abuse of Elderly. This oversight in reporting to law enforcement constitutes a deficiency in adhering to the facility's abuse reporting policy.
Failure to Revise Care Plan for Skin Impairment
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R3, to include actual skin impairment, specifically bruising on the right hand. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on comprehensive care plans requires that care plans be revised as the resident's condition changes. However, despite R3 being at risk for skin integrity impairment, the care plan did not reflect the bruising identified on 12/18/2024. A Facility Incident Report Form documented an allegation of staff-to-resident abuse on 12/17/2024, noting bruises on R3's right hand. During an interview, the MDS Coordinator confirmed that such information should be included in the care plan and stated that the treatment nurse or RN supervisor was responsible for updating the care plan with this information.
Medication Administration Error and Documentation Discrepancy
Penalty
Summary
The facility failed to ensure that services provided by a licensed nurse met professional standards of quality, resulting in a significant medication error. On 12/19/2024, an LPN administered the wrong medications to a resident, R2, after incorrectly identifying him as another resident, R6. The LPN relied on a verbal confirmation from R2, who mistakenly confirmed R6's last name, and a photograph on the Medication Administration Record (MAR) that she believed resembled R2. This error led to R2 being sent to the hospital for monitoring due to potential side effects from the incorrect medications. Further investigation revealed discrepancies in the documentation of medication administration. After the error was discovered, the LPN was relieved of her medication cart duties at 11:50 am and sent home. However, the LPN later documented administering medications to R2 at 12:44 pm, despite R2 being at the hospital by 12:15 pm. This documentation included signing off on ten medications that were scheduled for 9:00 am. Interviews with the RN Supervisor and the Director of Nursing confirmed that the LPN did not indicate administering R2's own medications and that the documentation was likely completed before leaving the facility.
Significant Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in actual harm. On December 19, 2024, an LPN administered the wrong medications to a resident, identified as R2, after failing to properly verify the resident's identity. The LPN asked R2 if his name was R2 or another resident's last name, R6, to which R2 incorrectly responded with R6's last name. The LPN then administered R6's medications to R2, which included a range of drugs such as allopurinol, amiodarone, and gabapentin, among others. Following the medication error, R2 experienced a fall in the bathroom and was subsequently sent to the hospital for evaluation. The hospital's emergency department determined that R2 had a vasovagal syncope episode while having a bowel movement, with additional differential diagnoses including medication error and polypharmacy. R2 was admitted for observation and remained hospitalized until December 24, 2024, after testing positive for influenza. Interviews with facility staff revealed that the LPN realized the error when she went to administer medications to R6 and found him in his room, wearing different clothing from the resident she had previously identified as R6. The LPN then checked on R2 and took his vital signs, which were normal, before reporting the incident to the RN Supervisor. The Medical Director later confirmed that the medication error was significant but not life-threatening for R2, and that the syncope episode was unrelated to the medication error.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication before leaving medications at the bedside. The facility's policy requires that drugs brought into the facility by residents or family must be verified and meet specific conditions before use, including physician orders for self-administration. However, a review of the resident's records showed no such orders, and observations revealed containers of topical medications at the resident's bedside. Interviews with facility staff, including LPNs and an RN, confirmed that medications should not be at a resident's bedside without proper assessment and physician orders. The staff acknowledged that daily rounds are conducted, and medications at the bedside should have been noticed and addressed. The presence of unsecured medications at the bedside posed a potential risk for unauthorized access by other residents and visitors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Perry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Church Home Rehabilitation And Healthcare | 5.1 mi | ★★★★★ | 0 | 0 |
| Fort Valley Crossing Of Journey Llc | 10.4 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - The Lodge, Llc | 11.8 mi | ★★★★★ | 7 | 0 |
| Warner Robins Rehabilitation Center | 13.7 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Warner Robins Llc | 14.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Summerhill Elderliving Home & Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.