Complete Care at Southpointe

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 out of 2 residents (R20) admitted to the facility with a history of pressure injuries received the necessary care and treatment services to avoid developing a pressure injury. R20 has a significant past medical history of pressure injuries, including needing surgical intervention with skin flaps to heal previous pressure injuries. R20 was at risk for the development of pressure injuries based upon this history. The facility failed to recognize R20's risk factors and implement resident specific measures to prevent the development of pressure injuries. R20 developed a facility acquired, full thickness, unstageable pressure injury.

Inspectors wroteBased upon interview and record review, the facility did not ensure the mandatory staffing data submitted for the fourth quarter of 2025 (July 1- September 31) was accurate based on payroll and other verifiable and auditable data in a uniform format according to specifications established by Centers for Medicare and Medicaid Services (CMS). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 92 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of the 97 residents residing in the facility. Certified Nursing Assistant (CNA)-R did not have an up-to-date background check completed within the four-year time frame.

Inspectors wroteBased on observation, interview, and record review, the facility did not store food in accordance with professional standards for food service safety on the unit refrigerators for three of the four units in the facility, potentially affecting the residents residing on 3 units in the facility. *Unit 1 refrigerator was 52 degrees, above the facility determined temperature range. *Unit 2 refrigerator was 34 degrees, below the facility determined temperature range. *Unit 3 did not have a thermometer in the freezer as indicated in the facility policy. An undated bag of opened, unsealed mixed fruit was observed in the freezer.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R62) of 2 residents reviewed abuse, neglect, misappropriation and exploitation was free from misappropriation of funds and possible exploitation. On 10/31/25 the facility was notified by Adult Protective Services of an allegation Certified Nursing Assistant (CNA)-Q had misappropriated R62's funds. Investigation revealed CNA-Q misappropriated funds from R62 using their debit card but also convinced R62 to provide R62 with cash, R62's PayPal account information to link R62's PayPal account to CNA-Q's account, and use of R62's cell phone.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 (R5) of 7 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R5 has an active MD order for a left palm guard to be worn. Surveyor observed R5 without a left palm guard in place multiple times during survey. R5's left palm guard was not part of R5's Comprehensive Care plan or Certified Nursing Assistant (CNA) Kardex.

Inspectors wroteBased on interview and record review, the facility did not ensure that proper notification was sent to the State Long-Term Care Ombudsman for 6 (R1, R2, R3, R8, R10 and R103) of 6 residents reviewed for transfers or discharges. *R1 was transferred to the hospital on 8/5/25 and 10/23/25. The facility did not notify the State Ombudsman of R1's hospitalizations. *R2 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R2's hospitalization. *R3 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R3's hospitalization. *R8 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R8's hospitalization. *R10 was transferred to the hospital on [DATE] and 2/3/26. The facility did not notify the State Ombudsman of R10's hospitalizations. [...]

Inspectors wroteBased on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to accurately code the Minimum Data Set (MDS) for three of 26 sampled residents (Resident (R) 23, R27, and R89) reviewed for MDS assessments. This deficient practice increased the potential for missed opportunities of care or services.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop a care plan for one of five residents (R)89) identified for smoking behaviors in the sample of 26. This failure has the potential to place the resident risk for unmet care needs and the inability to meet the maximum practicable level of functioning.

Inspectors wrote3) R19 was admitted to the facility on [DATE], and has diagnoses that include Dementia, Type 2 Diabetes, mild protein-calorie malnutrition, muscle weakness, physical debility, peripheral vascular disease, neuromuscular bladder dysfunction, history of cerebrovascular accident, and right and left below the knee amputations. R19's quarterly minimum data set (MDS) dated [DATE] indicated R19 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0 and the facility assessed R19 to require extensive assist with bed mobility, dressing, toileting, and total dependence with transferring using a Hoyer lift, and hygiene. R19 had a suprapubic catheter and was incontinent of stool. R19 had impairment to upper and lower extremities and had a high risk for developing pressure injuries with a Braden score of 9.0 on 8/9/2022. [...]

Inspectors wrote3.) R83's diagnoses includes diabetes mellitus, aphasia, cerebrovascular disease, and hypertension. The at risk for falls care plan initiated [DATE] & revised [DATE] documents the following interventions: * 42 inch bed keep needed items within reach ask resident what to place in reach. Initiated [DATE] & revised [DATE]. * Floor matt. Initiated [DATE] & revised [DATE]. * Low bed position. Initiated [DATE] & revised [DATE]. * Med review and [name] consult [DATE] MD (medical doctor) ordered labs. Initiated [DATE] & revised [DATE]. * Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated [DATE]. * Body pillow to right side when in bed to define bed parameters. Initiated [DATE] & revised [DATE]. * Bolstered Mattress. Frequent checks and incontinent care. [...]

Inspectors wroteBased on interview and record review the facility did not ensure adequate hydration for 1 (R108) of 1 resident reviewed for hydration. *R108 became dehydrated and needed to receive Intravenous (IV) rehydration. The facility did not implement interventions to prevent dehydration from occurring again, and R108 had to be sent to the hospital for IV insertion to receive IV fluids a second time.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 99 residents residing in the facility. *The facility's Water Management Plan (WMP) did not identify the two water fountains (bubblers) as a potential risk for Legionella growth and did not identify appropriate control measures for prevention of Legionella growth in the dead legs of the water fountains (bubblers).

Inspectors wroteBased on observation and interview the Facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 96 of 99 Residents that reside at the facility. On 07/26/23, Dietary Aide - JJ was observed touching ready to eat food with contaminated gloves and place the food on plates for residents to eat. Dietary Aide-JJ was observed removing their gloves and re-gloving without washing their hands.

Inspectors wroteBased on observation, interview and record review the facility did not ensure 1 (R11) out of 3 residents reviewed for indwelling catheters received the appropriate care. *R11 was admitted to the facility with an indwelling catheter and three weeks later was transferred to the hospital with a Urinary Tract Infection. Upon return to the facility, the facility did not assess the need for the indwelling catheter nor follow up with urology as recommended in the hospital discharge summary. Two months later in July, R11's catheter became clogged, and the facility was unable to irrigate it. At this point the physician noted R11's hospital discharge instructions and ordered a voiding trial.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R458) of 5 Residents reviewed. R458's physician orders does not include parameters of when to notify the physician if R458 were to have low/high blood sugars.

Inspectors wroteBased on record review and staff interview, the facility did not ensure the required information was provided to residents at the time of a transfer to the hospital. This was observed with 6 (R64, R59, R89, R103, R11, and R80) of 6 residents reviewed for hospital transfers. *R64's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request when transferred to the hospital on: 3/27/2023, 4/25/2023, 5/22/2023, and 7/8/2023 *R59's transfer notice did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; [...]