Southbrooke Manor Nursing and Rehabilitation Cente

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to ensure food products were labeled with discard dates for several prepared food products in the refrigerator in the food preparation area.2. The facility failed to keep their ice machine free of black circular spots on the inside of the ice machine.3. The facility failed to store mops and broom with head up in the kitchen cleaning closet on 02/17/2026. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 2 of 4 residents (Residents #13 and #43) reviewed for the accuracy of their medical records. 1. The facility failed to ensure that documentation on Resident #43's chart accurately reflected the diagnosis of dementia (decline of mental ability).2. The facility failed to accurately document Resident #13's blood pressure for 02/16/2026 and 02/17/2026 at 1PM, 02/17/2026 at 5PM. These failures could place residents at risk of receiving improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #3 and #5) reviewed for infection control, in that: 1. Resident #3 was observed with a catheter bag lying on the ground beside of Resident #3's bed on 08/05/2025. 2. On 08/06/2025, CNA D and CNA F failed to wear a gown while transferring and emptying Resident #5's urinary catheter, Resident #5 had an EBP sign outside the room door, which indicated the use of additional PPE (gown and gloves). These failures placed residents at risk of transmission of communicable diseases and infections, a decline in health status, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care/treatment. The facility failed to ensure Resident #1's admitting physician had the full hospital clinical discharge record which resulted in the physician holding a recommended medication (colchicine oral tablet 0.6 mg) for the resident. This failure could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interview sand record review, the facility failed to promote the residents' right to receive mail, for all facility residents. The facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts observed. The medication aide cart for the 400/600 halls contained 17 loose pills. The medication aide cart for the 300/500 halls contained 6 loose pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of three residents (Resident #63) reviewed for privacy. The facility failed to ensure MA B locked the computer, which exposed Resident #63's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 residents (Resident #20) reviewed for care plans. The facility failed to develop a care plan to address Resident #20's anti-coagulant medication use. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 1 of 21 staff (CNA A) reviewed for training. The facility failed to ensure that 1 of 21 staff (c) had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA staff who had been insufficiently trained while working in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 1 medication storage rooms. The facility failed to ensure the facility medication storage room was locked and secured while unattended. This failure could place residents at risk for harm by accidental ingestion of medications or drug diversion.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans: The facility failed to ensure Resident #1's care plan reflected that he ate quickly and was known to put large amounts of food in his mouth. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed, in that: Resident #1 displayed aggressive behaviors, was transported without adequate supervision, and attacked the transport driver. This failure could lead to residents who display aggressive behaviors hurting themselves or others due to inadequate supervision.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation, in that: The inside lip of the ice machine was soiled with a white chalk-like substance, boxes of dry goods were stored on the floor of the pantry, crumbs were found in a refrigerator, and a blood-like substance was found in a refrigerator. These deficient practices could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 10 residents (Residents #5, #20, #21 and, #57) reviewed for infection control, in that: 1. Medication Aide B did not sanitize the blood pressure cuff between resident #5 and resident #20 2. While providing incontinent care for resident #21, CNA A did not wash her hands after touching the bed remote and, CNA D did not change her gloves or wash her hands before touching a pair of clean briefs 3. During incontinent care CNA A allowed Resident #57's cleaned genitals and catheter tubing to come into contact with the resident's soiled adult brief. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 24 residents (Resident #57) reviewed for care plans, in that: Resident #57's care plan did not reflect the change in the resident's diet from regular to mechanical soft. This deficient practice could place residents at risk of receiving improper care.