Southern Pointe Living Center

Inspectors wroteBased on record review and interview, the facility failed to ensure RN coverage for 8 consecutive hours a day for 2 of 3 months of time details for registered nurses reviewed. The administrator identified 42 residents resided in the facility.

Inspectors wroteOn 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect a resident's right to be free from neglect. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. There was no documentation upon admission of Resident #3 having any skin issues. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed there were no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. [...]

Inspectors wroteOn 04/07/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident at risk for pressure ulcers was assessed and monitored to prevent pressure ulcers. Resident #3 admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. An admission assessment, dated 07/13/24, showed no skin concerns. Resident #3's quarterly assessment, dated 01/13/25, showed the resident required substantial/maximal assistance with all ADL's and had a Braden score of 16, placing them at increased risk of pressure ulcer/pressure injury development. The assessment showed no skin concerns. There were no documented skin assessments between 01/26/25 and 02/10/25. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to develop a comprehensive care plan related to nutrition and elopement for two (#22 and #50) of 12 residents reviewed for care plans. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders for three (#1,#22, and #34) of 12 resident reviewed for following physician orders. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure menus were followed for one meal service for the puree meals. The DM identified three residents who eat a puree diet.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident's rights to allow/receive visitors of the resident's choice for one (#33) of one sampled resident reviewed for visitation. The DON identified 42 resident who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were accurate for two (#4 and #7) of 12 sampled residents whose resident assessments were reviewed. The DON identified 42 residents who reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a PASRR I for a newly admitted resident who remained in the facility for one (#7) of one sampled resident whose PASRR I was reviewed. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident at risk for elopement was properly assessed and monitored to prevent elopement from the facility for one (#50) of two residents reviewed for elopement risk.

Inspectors wroteBased on observation, record review and interview the facility failed to conduct pain assessments for two (#10 and #24) of two resident reviewed for pain. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to complete a MRR in the required time frame for one (#7) of five residents reviewed for unnecessary medications. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnoses condition for one (#7) of five residents reviewed for unnecessary medication. The DON identified 42 residents who resided in the facility.

Inspectors wroteBased on record review, and interview, the facility failed to protect the resident's right to privacy of personal and medical record information for one (#1) of one sampled resident whose medical records were reviewed. The Resident Roster, dated 12/29/23, documented a census of 45 residents.

Inspectors wroteBased on record review and interview, the facility failed to document the required information regarding an involuntary discharge in the medical record for one (#1) of one sample resident who was reviewed for discharge. The Resident Roster, dated 12/29/23, documented a census of 45 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a fall with injury was documented in the medical record and the resident was monitored appropriately post fall for one (#1) of one sampled resident who was reviewed for a fall. The Resident Roster, dated 12/29/23, documented a census of 45 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a comprehensive care plan was developed to meet the residents' medical and nursing needs for five, (#4, 5, 15, 23, and #95) of five sampled residents whose care plans were reviewed. The facility failed to: a. develop a care plan for lymphedema for Res #4; b. develop a care plan for an indwelling urinary catheter for Res #5 and #15; c. develop a care plan for a PEG tube for Res #15; d. develop a care plan for oxygen therapy for Res #23 and e. develop a care plan for IV therapy for Res #95 The Resident Census and Conditions of Residents, completed on 01/10/23, documented a census of 35 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a comprehensive care plan was revised regarding fall interventions for two, (#22, and #23) of five sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents, completed on 01/10/23, documented a census of 35 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to assess fall risk for six (#4, 9, 22, 23, 33 and #94) of six residents reviewed for falls. The All Falls for Facility report, dated 01/10/22 through 01/10/23, documented 21 residents had falls in 2022. A Falls - Evaluation and Prevention Policy, revised 12/19, documented in part, It is the policy of this facility to assess/evaluate each resident for the potential for falls and fall risk and implement interventions for fall prevention as indicated .Residents should be evaluated for their fall risk .on admission .following a fall .quarterly . 1. Res #4 was admitted with diagnoses which included osteoporosis and dementia. A nursing note dated, 01/08/23 at 8:53 p.m., read in parts, Res found in floor by this nurse . There was no fall risk assessment completed upon admission, quarterly, or after the fall on 01/08/23. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff had demonstrated competencies to care for one (#95) of one resident reviewed for IV therapy. The corporate RN reported the facility had eight residents with IV therapy in the past 12 months.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure resident assessments were accurate regarding falls and an indwelling urinary catheter for two (#9 and #15) of five residents whose assessments were reviewed. The DON identified two residents with indwelling urinary catheters. The All Falls for Facility report, dated 01/10/22 through 01/10/23, reported 21 residents had falls in 2022.

Inspectors wroteBased on record review, and interview, the facility failed to provide care and services for the resident's highest possible level of functioning and well being for one (#95) of one resident sampled for IV therapy. The Resident Census and Conditions of Resident, dated 01/10/23 documented a census of 35 residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure one (#15) of two residents reviewed for an indwelling urinary catheter was evaluated for continued use of an indwelling urinary catheter. The DON identified two residents with an indwelling urinary catheter.

Inspectors wroteBased on record review, observation, and interview, the facility failed to follow their facility policies for one (#23) of one resident reviewed for oxygen therapy. The DON identified two residents who were on oxygen therapy.