Southbrook Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to promote and protect the rights of residents, including the right to make choices regarding dining preferences for two residents (Residents #29 and #86) out of 19 sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 94. The facility did not provide a policy regarding resident dining location and meal choice upon request. Review of the facility's New Hall Tray Menu for Breakfast, undated, showed:-Monday: Biscuits and Gravy, Eggs, Meat;-Tuesday: Eggs, Meat, Toast;-Wednesday: Pancakes, Meat, Eggs;-Thursday: Biscuits and Gravy, Meat, Eggs;-Friday: French Toast, Meat, Eggs;-Saturday: Oatmeal, Toast, Meat, Eggs:-Sunday: Pancakes, Eggs, Meat;-Special Dining Room Only: Monday: Donut, Tuesday: Muffin; Wednesday: Coffee Cake, Thursday: Cinnamon Roll, Friday: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for oxygen (O2) use for two residents (Residents #68 and #80) out of seven sampled residents and one resident (Resident #22) outside the sample. The facility's census was 94. Review of the facility's policy titled, Oxygen Administration, undated, showed:- Oxygen is administered under orders of a physician, except in the case of an emergency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during perineal (the area between the genitals and the anus) care for one resident (Resident #95) out of one sampled resident and during wound care for two residents (Residents #4 and #37) out of two sampled residents with a wound. The facility's census was 94. Review of the facility's policy titled, Wound Treatment Management, undated, showed: - Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of the dressing change; - The policy did not address infection prevention. Review of the facility's policy titled, Infection Prevention and Control, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) and the Nurse Aide (NA) Registry were completed prior to the employment start date for three employees out of 10 sampled employees. The facility's census was 87. Review of the facility's policy titled, Abuse, Neglect, and Exploitation revised July 2023, showed: - The names of all potential employees will be checked against the list maintained by the State of persons who may not be eligible for employment within a long-term care facility. CNA registry checked on all new hires and print copy for employee file prior to employment date and according to state law. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for one resident (Resident #63) out of 18 sampled residents. The facility's census was 87. Review of the facility's policy titled, MDS 3.0 Completion, dated 2024, showed: - Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the 3.0 version Resident Assessment Instrument (RAI) Manual; - A SCSA is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility, or a resident in the facility receiving hospice services discontinues those services (known as revocation of hospice care) and remains in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #7 and #51) out of 18 sampled residents. The facility's census was 87. Review of the facility's policy titled, MDS 3.0 Completion, dated 2024, showed: - According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity, using the Resident Assessment Instrument (RAI) specified by the state; - Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections; - All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for two residents (Resident #8 and #25) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy related to physician orders. 1. Review of Resident #8's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (thinking and social symptoms that interfere with daily function), hypertension (high blood pressure), and depression (low mood). Review of the resident's Physician Order Sheet (POS), dated 09/05/24, showed an order for weekly weights every day shift every Wednesday for monitoring. Re-weigh if greater than five-pound difference from previous weight. Notify Assistant Director of Nursing (ADON)/Medical Doctor (MD) if a weight loss or gain, start date 9/11/24. [...]

Inspectors wroteBased on interview and closed record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #89) out of one sampled closed discharge record. The facility's census was 87. Review of the facility's policy titled, Discharge Summary, undated, showed: - It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies; - Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary will be provided to the receiving care provider at the time the resident leaves the facility; - The discharge summary should include: A recapitulation of the resident's stay that includes, but is not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 87. Review of the facility's policy titled, Use of Plastic Gloves, undated, showed: - REMEMBER GLOVES ARE JUST LIKE HANDS. THEY GET SOILED. ANYTIME A CONTAMINATED SURFACE IS TOUCHED, THE GLOVES MUST BE CHANGED: after coughing or sneezing into hands; touching hair or face; after handling garbage or garbage cans; after handling anything soiled; after handling boxes, crates or packages; after picking up any item off the floor; and any time you touch any contaminated surface. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 87. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI), dated 2024, showed: - The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; - The QAA Committee shall be interdisciplinary and shall consist of a minimum of the Director of Nursing Services; the Medical Director or his/her designee; at least three other members of this facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other individual in a leadership role; and the Infection Preventionist; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during peri care (washing the genital and anal areas of the body) for two residents (Resident #26 and #74) outside of the 18 sampled residents. The facility failed to implement enhanced barrier precautions (EBP) for four residents (Resident #6, #42, #48, and #51) out of 18 sampled residents when they did not follow their policy and ensure proper signage and ensure staff were trained to wear appropriate PPE and ensure PPE was available outside or near the rooms of those residents on EBP. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund petty cash. This had the potential to affect all residents residing in the facility. The facility's census was 87. The facility did not provide a policy. Review of the facility-maintained resident petty cash log on 11/21/24 at 2:46 P.M. showed the balance listed as $553.88. Observation of the resident petty cash box count on 11/21/24 at 2:46 P.M. showed the Business Office Manager (BOM) counted a total of $453.88. The BOM said they keep $100.00 at the nurse's stations for residents to be able to access money during nights and weekends. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from November 2023 through October 2024. The facility's census was 87. Review of the facility's policy titled, Process for Ensuring Sufficient Surety Bond Amount, dated April 2022, showed: - Upon receipt of the resident trust bank statement for any quarter, the Business Office (or Administrator) will acknowledge the balance on the bank statement; - They will then refer to the communication from home office that indicates the amount of the surety bond for their facility; - They will multiply the bank balance by 1.5 (or 150%); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center for two residents (Resident #24 and #289) out of two sampled residents receiving dialysis. The facility census was 83. Review of the facility's policy titled, Dialysis, dated 03/2023, showed: - Will coordinate and collaborate with local dialysis facilities to meet the resident's nutrition and hydration needs; - Will provide ongoing daily monitoring and care of the resident's vascular access (a way to reach the blood for dialysis); - Will provide ongoing monitoring for dialysis related complications such as bleeding, access site infection, or hypotension (low blood pressure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs of five residents (Resident #27, #45, #135, #187, and #191) out of 18 sampled residents. The facility census was 83. Review of the facility's policy titled, Resident Centered Care Plan Process, dated 12/01/16, showed: - Care planning is based on data collected from resident assessments; - Care plan will include resident care goals that are reasonable and measurable; - The needs of the resident, goals, time frames, required services and the social settings are critical considerations in determining the plan of care. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician's orders for four residents (Resident #19, #45, #187, and #191) out 18 sampled residents. The facility census was 83. Review of the facility's policy titled, Physician's Orders, undated, showed: - The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality; - Facility will maintain a schedule of diagnostic tests in accordance with the physician, physician assistant, nurse practitioner or clinical nurse specialist's orders in accordance with state law, including scope of practice laws; - Qualified nursing personnel will submit timely requests for physician ordered services to the appropriate entity; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff discarded expired stock medication from the medication room. The facility also failed to discard discontinued medication for one resident (Resident #11) and to discard expired medication for one resident (Resident #33). The facility census was 83. The facility did not provide a policy for expired or discontinued medications disposal. Observation of the facility's medication room on 11/02/23 at 2:00 P.M., showed: - One opened package of stock hemorrhoidal suppositories, expired 10/23; - One bottle of unopened Latanoprost (glaucoma (group of eye conditions that can cause blindness) medication) ophthalmic solution 0.005 percent (%), expired on 10/31/21 in the emergency kit; [...]