Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Summer Commons during CMS and state inspections, most recent first.
The facility did not complete required neurological assessments or post-fall observations for three cognitively impaired residents after unwitnessed falls, as mandated by facility policy. In several cases, neurological checks were either missing or incomplete, and documentation of post-fall monitoring was lacking, despite residents reporting head injuries or having low BIMS scores. Facility leadership confirmed these lapses in assessment and documentation.
An opened, undated multidose vial of TB was found in the August Unit med room refrigerator during survey observation with the RN Manager. The vial's manufacturer instructions stated it should be discarded 30 days after entry, and the RN Manager confirmed the issue and discarded the vial.
Failure to maintain hand hygiene during medication preparation. During a med pass on the August unit, an RN was observed preparing meds for a resident, picking up a piece of foil from the floor, and then continuing to prepare additional meds without performing hand hygiene. The facility’s med administration guidelines require good hand hygiene and sanitizer use between hand washings when returning to the med cart or prep area.
Failure to Report Resistant Wound Culture Results: A resident with chronic venous insufficiency and chronic lower-extremity wounds had a wound C&S that identified Proteus mirabilis resistant to the ordered Bactrim. Although the wound clinic NP was notified, the physician was not informed of the resistant result, the antibiotic was not changed based on the culture, and the DON confirmed the result was not included in the facility’s infection tracking and monitoring logs.
Care plans were not reviewed and revised by the IDT with resident participation to the extent possible after MDS assessments for two residents, and several care plans were not updated to match current needs. A resident with a guardian had no evidence of an IDT care plan meeting, another resident’s IDT met while the resident was eating, and two other residents had outdated plans for falls/self-care and communication, including a call bell kept out of reach and a communication plan that still listed writing even though the resident could not write.
The facility failed to show that required QAPI members attended quarterly meetings. Review of attendance sheets showed the Medical Director was not documented at one meeting, the Infection Preventionist was not documented at another, and the DON was not documented at a third meeting. The Administrator confirmed the finding.
Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to properly assess and monitor residents following unwitnessed falls, and did not adhere to its own Fall Management and Neurological Assessment policies. According to the facility's policies, a neurological assessment is required after any unwitnessed fall for residents with a Brief Interview for Mental Status (BIMS) score of 12 or lower, or when a head injury is suspected. However, documentation revealed that for three residents with cognitive impairment, these assessments were either not completed or only partially completed after unwitnessed falls. One resident with a BIMS score of 5 experienced two unwitnessed falls. After the first fall, there was no evidence of a post-fall observation or neurological assessment. Following the second fall, where the resident reported hitting their forehead, only 5 out of the required 15 neurological checks were documented. Another resident with a BIMS score of 11 had an unwitnessed fall and only 3 of the 15 required neurological assessments were completed, despite the policy requirements. The Director of Nursing confirmed that staff did not follow the facility's policy in this case. A third resident, with severe cognitive impairment (BIMS score of 3), had multiple unwitnessed falls in a short period. Documentation showed that after one fall, the resident was sent to the emergency department, but for another fall, there was no evidence of post-fall evaluation or neurological assessments. Neurological assessments were only started after a subsequent fall and were not completed for all required intervals. Facility leadership confirmed the lack of appropriate monitoring and documentation for these incidents.
Opened TB Vial Left Undated in Medication Refrigerator
Penalty
Summary
The facility failed to adequately date and properly dispose of an opened multidose vial of Tuberculin Purified Protein Derivative (TB) in 1 of 2 medication storage rooms observed, the August Unit medication room. During observation with the Registered Nurse Manager, the refrigerator contained an opened and undated TB vial. The vial's manufacturer instructions stated that once entered, it should be discarded after 30 days. The Registered Nurse Manager confirmed the vial was opened and undated and then discarded it at the time of the observation.
Failure to Maintain Hand Hygiene During Medication Preparation
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to prevent the development and transmission of disease and infection related to hand hygiene during medication administration for 1 of 4 residents observed. The facility’s Medication Administration- General Guidelines, effective 5/1/18, state that the person administering medications must adhere to good hand hygiene, including washing hands thoroughly, and that hand sanitization is done with an approved sanitizer between hand washings when returning to the medication cart or preparation area, assuming hands have not touched a resident or potentially contaminated surface. During observation of the medication administration pass on the August unit, RN #1 was seen preparing medications for a resident, then stopping to pick up a piece of foil off the floor, and then proceeding to prepare additional medications without performing hand hygiene. The surveyor discussed the lack of proper hand hygiene during medication preparation with RN #1.
Failure to Report Resistant Wound Culture Results
Penalty
Summary
The facility failed to ensure that the physician was notified of wound culture and sensitivity results when organisms were identified as resistant to the antibiotic already ordered for a resident with chronic venous insufficiency and chronic wounds of both lower extremities. The resident was followed weekly by the wound care specialist and received daily dressing changes. A physician order was in place for sulfamethoxazole/trimethoprim (Bactrim) suspension, and a wound culture specimen had been obtained from the resident's wound. The culture results showed multiple organisms, including Proteus mirabilis, Staphylococcus aureus, and Enterobacter cloacae complex, and Proteus mirabilis was resistant to the prescribed antibiotic. Although a nursing note stated the wound culture results were received and the nurse practitioner was advised, the physician was not made aware that one organism was resistant to Bactrim. The medical director later stated she had not been informed of the resistant result and would have changed the antibiotic to a third generation cephalosporin. The DON also confirmed the resident's culture results were not included in the facility's infection tracking, trending, and monitoring logs, and the facility failed to identify and report the culture results to ensure the appropriate antibiotic was used under its antibiotic stewardship program.
Care plans not reviewed with residents and not kept current
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team after MDS assessments for two residents, and failed to keep care plans current for residents with needs related to falls, self-care deficit, and communication. Resident #34 stated he/she was not aware of being invited to participate in the plan of care, and the medical record lacked evidence that an IDT care plan meeting was held after the Quarterly MDS. The LSW stated the resident had a guardian and that attempts were made to find a meeting time, but the email exchange provided showed only planning attempts in June and no further efforts were made to ensure the IDT meeting occurred. Resident #32 stated staff did not tell him/her about participation in the plan of care, and the record lacked evidence that the 8/21/25 IDT meeting included the resident to the extent possible; the LSW stated the meeting occurred while the resident was still eating and the team proceeded without him/her, with follow-up by the unit manager afterward. Resident #43 was observed multiple times sitting in a recliner with the call bell lying on the bed or wrapped around the bedside rail across the room and out of reach. The resident’s POA stated the resident could not push the call bell and had never been able to use the neck button at home. The care plan, last updated on 7/22/25, included interventions to place the call bell within easy reach and keep it within reach at all times for fall risk and self-care deficit, but the RN#2 stated the resident probably did not know what the call bell was and confirmed the care plan did not reflect the resident’s current status. Resident #6’s MDS indicated unclear speech and inconsistent ability to make self understood and understand verbal content, while the care plan stated the resident communicated mostly by reading/writing, pointing, picture paper, and nodding or shaking the head. During observation and interviews, the resident could answer yes/no, point, and use facial expressions, but could not write sensical words when given paper and pen, and the RN manager confirmed the resident could not communicate by writing and that the care plan did not reflect the current communication status.
QAPI Committee Lacked Evidence of Required Member Attendance
Penalty
Summary
The facility failed to present evidence that the required members of the Quality Assurance and Performance Improvement (QAPI) group attended at least quarterly meetings. During review of the facility’s QAPI program, attendance sheets for three quarterly meetings in 2025 were examined. The January 2025 QAPI attendance sheet did not show that the Medical Director attended the meeting, the April 2025 attendance sheet did not show that the Infection Preventionist attended, and the July 2025 attendance sheet did not show that the DON attended. On 8/27/25 at 3:30 p.m., the Administrator confirmed the finding during discussion with the surveyor.
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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.
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Nursing homes near Sanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinnacle Health & Rehab At Sanford | 1.5 mi | ★★★★★ | 0 | 0 |
| Pinnacle Health & Rehab At N Berwick | 10 mi | ★★★★★ | 5 | 0 |
| Kennebunk Center For Health & Rehabilitation, Llc | 11.2 mi | ★★★★★ | 15 | 0 |
| River Ridge Center | 11.5 mi | ★★★★★ | 0 | 0 |
| Rochester Manor | 14 mi | ★★★★★ | 4 | 0 |
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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.