Southeast Rehabilitation & Skilled Care Center

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council regarding staff members wearing a name tag for identification were acted upon to resolve the issue.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed:To ensure the carpets were clean, free of odor, and without lifting on one unit (unit 200) out of four;To ensure the window unit air conditioners were maintained in a clean and sanitary manner on three out of four units;To ensure the dining room on one out of four units was well lit during dining;To ensure a clean, safe, homelike environment on the 100 unit; To ensure a clean and sanitary environment and tube feeding equipment for Resident #12; andTo ensure room [ROOM NUMBER] was maintained in a clean and sanitary manner.

Inspectors wroteBased on observations, interviews, and records reviewed, for three Residents (#80, #144, and #135), of 39 sampled residents, the facility failed to ensure that individualized, comprehensive care plans were developed, consistently implemented, and revised as needed. Specifically, the facility failed:1. For Resident #80, to develop and implement a care plan intervention after he/she sustained a fall;2. For Resident #144, to develop and implement a smoking care plan; and3. For Resident #135, to follow the care plan and implement side rails for fall prevention and develop a care plan for post-traumatic stress disorder (PTSD).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one Resident (#4), out of a total sample of 39 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure wound care orders were transcribed per wound physician recommendations, to perform wound care per physician's orders, and to adhere to clean technique with proper hand hygiene during dressing changes.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure an environment that was free from accidents and hazards for nine Residents (#111, #4, #12, #68, #54, #13, #43, #80, and #144), out of a total sample of 39 residents. Specifically, the facility failed:1. For Resident #111, to ensure the Resident's previous elopement was investigated and had effective interventions in place to prevent a second elopement from the facility;2. For Residents #4 and #12, to ensure fall prevention/injury mitigation interventions were implemented;3. For Resident #68, to ensure new interventions were developed and implemented following a fall;4. For Resident #54, to ensure he/she was supervised while smoking, not lighting cigarette butts off the ground to smoke, and ensure the smoking area was free of disposed cigarette butts on the ground;5. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure two Residents (#104 and #43) were free from significant medication errors when they were not administered the medication as prescribed, placing him/her at risk for adverse reactions. Specifically, the facility failed:1. For Resident #104, to administer Amlodipine Besylate Tablet 10 milligrams (mg) (for blood pressure) per physician's order; and2. For Resident #43, to administer Eliquis 5mg (blood thinner).

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to ensure the nurse responsible for liquid controlled substance medications stored in the refrigerator were only accessible to that nurse in two of two medication rooms reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow prescribed diets and follow therapeutic menus to ensure the residents' daily nutritional and special dietary needs were met as prescribed by the physician. Specifically, the facility failed to:1. Follow prescribed menus for the correct percentage of milk; and2. Failed to prepare the correct therapeutic substitutions for three of three meals observed.

Inspectors wroteBased on interview, observation, and record review, the facility failed to have available a vegan menu which was prepared in advance and followed to meet the needs of one Resident (#59), out of a total sample of 39 residents.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to provide food to residents that was palatable and served with an appetizing presentation for one of two test trays.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adaptive equipment for two Residents (#80 and #109), out of a total sample of 39 residents. Specifically, the facility failed:1. For Resident #80, to provide hollow-handled silverware (adaptive eating utensils) during meals; and2. For Resident #109, to provide a rocker knife (adaptive knife cuts food with a rocking motion) during meals.

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 potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections.

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal immunizations for three eligible Residents (#4, #9, and #109), out of a total sample of five residents.

Inspectors wroteBased on record review and interview, the facility failed to provide education, assess for eligibility, offer and administer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#4, #9, #71, #87, and #109), out of a total sample of five residents reviewed for immunizations and for five employees, out of five employee records reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that signed written informed consent for the administration of psychotropic medications (drugs that affect mental processes used to treat a variety of mental health conditions) were obtained from the Health Care Proxy (HCP), which included providing the resident/resident representative with information related to the risks and benefits of the medications, prior to administering them for one Resident (#4), out of five sampled residents selected for unnecessary medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Physician or the Nurse Practitioner (NP) of recommendations or changes in condition for two Residents (#80 and #109), out of a total sample of 39 residents. Specifically, the facility failed:1. For Resident #80, to notify the Physician/NP of a fall; and2. For Resident #109, to notify the Physician/NP of a significant weight loss.

Inspectors wroteBased on observations, interviews, and records reviewed, for five Residents (#9, #90, #109, #12, and #14), of 39 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed:1. For Resident #9, to follow the physician's order for air mattress settings;2. For Resident #90, to administer Pyridoxine Hydrochloride (Vitamin B6) per physician's orders;3. For Resident #109, to obtain his/her weight per physician's orders; 4. For Resident #12, to implement hand rolls per physician's orders; and 5. For Resident #14, to administer an inhaler per physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a portable oxygen (O2) cannister for a resident requiring two liters of continuous O2 for one Resident (#71), out of total sample of 39 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#148 and #135), out of a sample of 39 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed:1. For Resident #148, to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization; and2. For Resident #135, to complete a trauma informed assessment with identified triggers and implement a care plan, specifically for side rails on his/her bed for security at nighttime.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when one of two nurses observed during the medication pass made four errors out of 29 opportunities, resulting in a medication error rate of 13.79%. Those errors impacted two Residents (#104 and #43).

Inspectors wroteBased on interview and record review, the facility failed to maintain completed medical records for two Residents (#14 and #97), out of a sample of 39 residents. Specifically, for Residents #14 and #97, the facility failed to ensure evaluations were completed in a timely manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure for one Resident (#80), out of 39 sampled residents, that the call bell system (a communication system for residents to contact staff for assistance) in the Resident's bathroom was functional.

Inspectors wroteBased on record review and interview, the facility failed to report the change in Director of Nurses (DON) in June 2025 to the state agency (SA) in the Health Care Facility Reporting System (HCFRS) as required.

Inspectors wroteBased on resident and staff interview, the facility failed to ensure that staff delivered packages mailed to the residents on Saturdays and Sundays.

Inspectors wroteBased on record review and interviews, the facility failed to ensure timely physician visits for one Resident (#97), out of a sample of 39 residents. Specifically, the facility failed to ensure alternating and timely physician's visits for Resident #97.

Inspectors wroteBased on record review and interview, the facility failed to ensure three of four Certified Nursing Assistants (CNA) employee records reviewed had an annual performance review at least every 12 months.

Inspectors wroteBased on record reviews and interviews for one of five sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when upon readmission Resident #1's medications were not reconciled accurately, resulting in multiple medication errors related to missed doses.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Maintain the main kitchen, including the floors, shelves, and dry storage room floor in a sanitary condition; 2. Ensure food stored in the main kitchen reach-in refrigerator was labeled and dated; 3. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 4. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain medical records securely and accurately in accordance with accepted professional standards. Specifically, the facility failed to: 1. Maintain documentation of physician visits; and 2. Maintain the secure medical record shredding bins on the resident units and by staff offices.

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment in safe working order. Specifically, the facility failed to maintain: 1. Three of four microwaves located in the resident kitchenettes on the 200, 300 and 400 units, 2. The milk refrigerator unit located in the dry storage room across from the main kitchen, and 3. The grease trap by ensuring it was emptied as recommended by the consultant company.

Inspectors wroteBased on observation and interview, the facility failed to maintain the plumbing in the main kitchen in working order to prevent a buildup of pungent odors, puddling of water on kitchen floor in two areas, and the buildup of a black substance leaching form the wall between the wall between the dish machine and the prep the sink. Specifically, the facility failed to: 1. Maintain the drainpipes within the wall between the dish machine and the prep sink to prevent leakage of water/sewage into the main kitchen, build-up of a black substance oozing from the door jamb, and a foul, pungent odor emanating from the wall and left corner of the kitchen permeating out into the main hallway; 2. Maintain the drain which services the hand washing sink and the overflow valve to the ice machine from draining directly onto the kitchen floor into the floor drain. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure residents in one of four dining rooms had a dignified dining experience. Specifically, residents seated at the same tables were not fed at the same time, resulting in residents having to sit and watch while others ate or were fed by staff. In addition, staff stood while assisting residents with eating.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one Resident (#134), out of a total sample of 29 residents, had information in advance to exercise their rights. Specifically, the facility failed to involve and inform the Resident, who was responsible for his/her own care, about care and treatment, including the risks and benefits of administration of psychotropic medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were not self-administered without a physician's order and an assessment for self-administration was completed for one Resident (#34), out of a total sample of 28 residents.

Inspectors wroteBased on observations, interviews, and policy 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 potential transmission of communicable diseases and infections within the facility. Specifically, the facility failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use when providing care and services to residents requiring precautions to prevent the possible spread of germs and illnesses.

Inspectors wroteBased on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to: 1. Ensure antibiotics prescribed were necessary for one Resident (#114), and 2. Ensure antibiotics were monitored/reassessed 48-72 hours after initiation to ensure the treatment remained appropriate for five Residents (#114, #1B, #1A, #37, and #66), out of a total sample of five residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on the benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offered and administered the influenza and pneumococcal immunizations in a timely manner for three out of five Residents sampled (#45, #106, and #8). Specifically, the facility failed: 1. For Resident #45, to educate the Resident and/or Resident's representative on the benefits and potential side effects of the influenza and pneumococcal vaccines, offer the immunizations, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccines and place in the Resident's medical record; 2. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer the COVID-19 vaccination per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#8 and #107), out of a total sample size of five residents reviewed for immunizations.

Inspectors wroteBased on records review, interviews and observations for one of three sampled residents (Resident #3), the Facility failed to ensure that the interdisciplinary team completed an assessment for safe self-administration of medications, when on 03/27/24 and 03/28/24 prescription medications were observed on Resident #3's bedside table, which he/she said were left there all the time by nursing for him/her to self administer.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), who was alert, oriented, and whose preference including being able to receive a shower weekly, the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of receiving a weekly shower.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure he/she was free from verbal and mental abuse from a staff member, when Resident #2 and Resident #3 witnessed and reported that Nurse #1 threatened and intimidated Resident #1. On 11/07/23, Resident #1 became upset with Nurse #1 because he/she wanted leave the unit to go down for lunch, but could not go until Nurse #1 checked his/her blood sugar and administered his/her medications, Resident #2 and Resident #3 witnessed as Nurse #1 made a grrrrrr type sound directed toward Resident #1, held both of his fists up and then stated he wanted to punch/hit Resident #1 in the head. Resident #1 said he/she felt threatened and was scared by Nurse #1's actions.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 11/06/23, after being made aware of and substantiating Resident #1's allegation that Nurse #1 was verbally abusive and had threatened him/her, there was no documentation to support that staff monitored Resident #1 for negative outcomes, and/or provided counseling and support to him/her for three days (72 hours) following the incident, per Facility Policy.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact and dependent on staff for transfers and care, the Facility failed to ensure they obtained and maintained evidence that a thorough investigation was completed, after being made aware on 7/21/23 of an allegation of potential neglect.

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to ensure staff implemented written policies and procedures for allegations of abuse for one Resident (#35), out of a sample of 33 residents. Specifically, the facility failed to ensure an allegation that staff pulled Resident #35's arm when turning and repositioning which caused pain, said the Resident smelled and inquired about his/her children's whereabouts, resulting in the Resident becoming scared and anxious, was a) thoroughly investigated; and b) the alleged staff member was removed pending an investigation; and c) the incident was reported to the Department of Public Health per the facility's policy.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff thoroughly investigated an allegation of abuse, for one Resident (#35), out of a total sample of 33 residents, resulting in the Resident becoming scared and anxious.

Inspectors wroteBased on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to: 1.) Identify and address a water management program used to address and mitigate the ongoing concern for Legionella bacteria located in the facility's water system; and 2.) Address the use of graduate nurses for the care and treatment of residents and the required oversight and education required during the COVID-19 pandemic.

Inspectors wroteBased on observation, interview, record, and policy 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 potential transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1.) For four Residents (#138, #35, #261, #20), ensure testing was conducted for Legionnaire's disease for resident's experiencing signs and symptoms per facility policy after an identified outbreak of Legionella was detected in the facility's water management system; [...]

Inspectors wroteBased on interviews, record review, and document review, the facility failed to notify residents, resident representatives, and families of positive COVID-19 cases (staff or resident) by 5:00 P.M. the following day as required.

Inspectors wroteBased on a Resident Group meeting, interview, and document review, the facility failed to ensure grievances and concerns brought forth by the Resident Council were addressed and/or responded to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented a system to ensure that all mechanical and electrical kitchen equipment were maintained in safe operating condition.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure the resident and/or their representative were fully informed in advance and given information necessary to make health care decisions, including the risks and benefits of psychotropic and antipsychotic medications, prior to their use for two Residents (#142 and #30), out of a total sample of 33 residents. Specifically, the facility failed to: 1. For Resident #142, obtain a written consent prior to administering Duloxetine (anti-depressant) and Quetiapine (anti-psychotic). 2. For Resident #30, obtain a written consent prior to administering Olanzapine (anti-psychotic), Trazodone (antidepressant), and Buspirone (anti-anxiety).

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff reported an allegation of abuse to the Department of Public Health (DPH) within two hours, for one Resident (#35), out of a sample of 33 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one Resident (#70), from a total of 33 residents. Specifically, the facility failed to develop a comprehensive care plan for the use of an anticoagulant medication and insulin.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to evaluate the effectiveness and revise the comprehensive care plan for one Resident (#25), out of a total sample of 33 residents. Specifically, the facility failed to review and revise the care plan for the resident's skin condition and treatments provided.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to meet professional standards of care for two Residents (#311 and #162), out of a total sample size of 33 residents. Specifically, the facility failed: 1. For Resident #311, to follow the physician's orders and provide an air mattress; and 2. For Resident #162, to notify the physician when a resident left the facility against medical advice (AMA) and document as per facility policy.

Inspectors wroteBased on interview and record review, the facility failed to ensure: a. Medication reconciliation was performed upon admission, b. Signs and symptoms of bleeding were monitored when receiving Heparin medication (anticoagulant/blood thinner), c. Comprehensive care plan was developed for a resident receiving Heparin with recent history of acute post-hemorrhagic anemia (sudden loss of blood) requiring blood transfusions, and d. Communicate abnormal labs to physician or nurse practitioner, for one Resident (#311), out of a total sample size of 33 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility 1. Failed to ensure that for one Resident (#100) with an external catheter, out of a sample size of 33 residents, that staff were aware and followed the facility's policy to ensure the Resident used the appropriate technique and hygiene to perform self-catheterization to minimize the risk of acquiring a urinary tract infection (UTI) for a resident who is at high risk for an infection; and 2. Failed to ensure physician's orders and care plans were updated to reflect the Resident's use of an external catheter and the Resident performing self-catheterization.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure one of one Resident (#45) who was fed exclusively via a gastrostomy feeding tube, from a total sample of 33 residents, received adequate nutrition and hydration to prevent weight loss. Specifically, the facility failed to accurately monitor the Resident's intake of tube feeding formula to ensure the Resident was receiving the prescribed formula, including rate and volume within a 24-hour period, to meet his/her nutritional needs.

Inspectors wroteBased on staff interviews and document review, the facility failed to ensure that nursing staff were assessed to have competencies and skill sets required to provide safe and effective nursing care to residents of the facility. Specifically, the facility failed to ensure that one Graduate Nurse (GN) (a nurse who has completed academic studies but has not completed the requirements to become a Licensed Practical or Registered Nurse) successfully completed a medication administration competency prior to administering medications independently.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure the physician and/or Nurse Practitioner (NP) was notified of laboratory results which fell out of the clinical range for one Resident (#311), out of a total sample size of 33 residents.

Inspectors wroteBased on staff interview, record review, and review of the Hospice contract agreement, the facility failed to ensure two Residents (#29, #123) of seven residents who receive hospice services, from a total of 33 residents, met professional standards for hospice services. Specifically, 1. For Resident #29, the facility failed to create and implement an integrated care plan, failed to provide coordination of care between the hospice provider and the facility, and failed to orient hospice staff to the facility prior to providing care per facility policy; and 2. For Resident #123, the facility failed to create and implement an integrated hospice care plan.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment for the kitchen staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure Nurse Staffing Data was posted on a daily basis in a prominent place and readily accessible to residents and visitors as required.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure staff completed the Comprehensive MDS Assessment within the required time frame for one Resident (#1), out of a total of three resident assessments reviewed.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to complete a Quarterly MDS assessment timely for two Residents (#2 and #3), from a total of three resident assessments reviewed.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to electronically transmit MDS data to the Centers for Medicare and Medicaid Services (CMS) processing system within 14 days of the MDS completion date for three Residents (#1, #2, #3), out of three resident assessments reviewed.