Southpoint Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician (Resident # 83), obtain a physician order on a resident's medical record for the use of a Bilevel positive airway pressure machine, a device that helps a person breathe by delivering pressurized air into the airways, (Resident # 296) and apply signage indicating no smoking, the use of oxygen outside the resident's room for 4 of 4 residents reviewed for oxygen use (Resident #83, #296, #101 and #49).

Inspectors wroteBased on observations, record reviews, and staff and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of resident property for 1 of 3 residents reviewed for misappropriation (Resident #300).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 31 residents whose MDS assessment were reviewed (Resident #75).

Inspectors wroteBased on record reviews, resident interview, resident's emergency contact interview, and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and significant change Minimum Data Set (MDS) assessments for 1 of 31 residents reviewed for care planning (Resident #62).

Inspectors wroteBased on record review, observation, and staff and resident interviews, the facility failed to provide care according to accepted professional standards when a nurse administered medication but did not observe the resident take her medications and left them at the bedside for 1 of 1 resident with medications observed at bedside (Resident #93).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to provide daily cholecystostomy (a surgical opening in the gallbladder to place a catheter for draining excess bile) dressings as ordered by the physician for a resident who had a biliary (a network of organs and vessels that make, store and transfer bile, a fluid the liver makes that helps digest food) tube inserted into the right upper abdominal wall for drainage of biliary fluid for 1 of 3 residents reviewed for professional standards of care (Resident #5).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain a secure medication cart and accurate controlled medication records for 1 of 2 residents (Resident #301) reviewed for use of controlled medications.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain a complete and accurate medical record when documenting cholecystostomy care for 1 of 31 residents who medical records were reviewed (Resident #5).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene between the removal of soiled gloves and the application of clean gloves during wound care for 1 of 5 staff observed for infection control practices (Nurse #1).

Inspectors wroteBased on record review and interviews with residents, staff, physician assistant, and pharmacists, the facility failed to ensure antibiotics were available for the nurses who were responsible for administering the antibiotics. This resulted in a delay of over 24 hours in initiating antibiotic therapy for two residents (Residents # 5 and # 6) out of five sampled residents whose medications were reviewed.

Inspectors wroteBased on record review, staff interviews, and a recorded 911 call, the facility failed to protect a resident's right to be free from neglect when they did not effectively respond to a medical emergency. This occurred for 1 of 1 resident reviewed for neglect. Resident #232 was found to have a critical low blood sugar of 28 and was unresponsive. Nurse #7 failed to complete a nursing clinical assessment, failed to initiate emergency procedures within the nursing home and with 911. Nurse #7 also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation to the rest of the nursing staff. Emergency medical services (EMS) were not called until 6:56 am. Resident #232 expired on [DATE]. [...]

Inspectors wroteBased on record review, staff interviews, and a recorded 911 call, the facility failed to implement emergency procedures, when a resident who was a known brittle diabetic was discovered to have a blood sugar of 28 and was unresponsive. Nurse #7 failed to complete a nursing clinical assessment, failed to initiate emergency procedures within the nursing home and with 911. Nurse #7 also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation. Resident #232 expired on [DATE]. This occurred for 1 of 1 resident reviewed for neglect (Resident #232). Immediate jeopardy began on [DATE] when the facility failed to immediately and effectively respond to a medical emergency. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of compliance. [...]

Inspectors wroteBased on record review, staff interviews, and a recorded 911 call, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures within the nursing home and with emergency medical services for 1 of 1 resident (Resident #232) reviewed for neglect. Nursing staff failed to complete nursing clinical assessments (including vital signs), failed to immediately initiate emergency procedures within the nursing home and with 911 when a nurse asked for a glucagon injection. Nursing staff also delayed in activating 911, demonstrated no urgency with the 911 call, and did not relay accurate information of the situation to the 911 operator. Resident #232 expired on [DATE]. Immediate jeopardy began on [DATE] when nursing staff failed to immediately and effectively respond to a medical emergency. [...]

Inspectors wroteBased on record reviews, residents and staff interviews, the facility failed to review, revise, and include the participation of residents/resident representatives after the completion of Minimum Data Set (MDS) assessments for 5 of 5 residents reviewed for care plan participation (Residents # 93, Resident #37, Resident # 53, Resident #104, and Resident #97).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired multi-dose pen injectors of insulin and expired tablets from the medication cart drawer for 2 of 7 medication administration carts (100 and 300 halls), failed to remove the expired medications, enteral feeding formula supplements and supply kit from the medication storage rooms (medication storge rooms #1 and #2).

Inspectors wroteBased on observations, staff, Regional Director of Dietary Operations, and Registered Dietitian (RD) interviews, and record review, the facility failed to have no greater than a 14-hour lapse between the provision of a substantial evening meal and breakfast the following day for residents served their meals on 4 of 8 meal carts (400 Hall Cart-1; 400 Hall Cart-2; 400 Hall Cart-3 and 500 Hall Cart) utilized for meal service.

Inspectors wroteBased on observations, staff and the Regional Director of Dietary Operations interviews, and record reviews, the facility failed to: 1) Label, date, and discard expired food items stored in the refrigerator in 1 of 2 Nourishment Rooms (300 Hall Nourishment Room) observed; and 2) Maintain thermal pellets in good condition and without chipped edges for 6 of 60 pellets observed to be available for use as the meal service tray line was conducted.

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 1/10/23, and 8/26/21 and for complaint investigation dated 8/18/23, 12/22/21, and 8/2/21 to achieve and sustain compliance. These were for recited deficiencies on the recent recertification and complaint investigation survey dated 2/9/24. The deficiencies were in the following areas: reporting of alleged violations, discharge planning process, treatment/services to prevent /heal pressure ulcers, label/ store drugs and biologicals, food procurement, store/prepare/serve - sanitary and resident records - identifiable information. [...]

Inspectors wroteBased on record review, observations, resident, and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 1 sampled resident observed with medication at the bedside (Resident #97).

Inspectors wroteBased on staff interviews and record review, the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper chart for 2 of 32 residents reviewed for advance directives (Resident #100 and Resident #73).

Inspectors wroteBased on staff interviews, family interview, physician interview and record review, the facility failed to notify the responsible person (RP) and physician of facility acquired pressure wounds (Resident # 181), facility acquired non-pressure wound (Resident #5) and a resident pulling out the urinary catheter reviewed for 3 of 6 residents reviewed for change of condition notification.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete and provide a written grievance summary for 1 of 1 sampled resident (Residents #280) reviewed for grievances.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit an Initial Allegation Report to the State Agency, Adult Protective Services (APS), and the police within the required timeframe for 1 of 1 resident (Resident #232) reviewed for neglect. The facility was officially notified of neglect on 4/2/24 at 6:27 pm when an immediate jeopardy template was issued. The facility did not submit an initial report to the State Agency within the required timeframe following notification.

Inspectors wroteBased on record review, family, home health agency, physician, staff interviews, the facility failed to implement an effective discharge planning process that included ensuring the resident's caregiver and the home health agency were informed of the resident's medication orders, wounds, and the treatment that was required for the wounds. This was for 1 of 3 residents reviewed for discharge (Resident #181).

Inspectors wroteBased on record review, and staff interview, the facility failed to complete a recapitulation of stay for 1 of 4 closed records reviewed for planned discharge to the community(Resident #181).

Inspectors wroteBased on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interest and needs for 1 of 2 cognitively impaired residents reviewed for activities (Residents #74).

Inspectors wroteBased on record review and staff, family, and physician interviews, the facility failed to assess, document the pressure wound(s) identified and document the treatment provided for the identified wound(s) on the buttock for 1 of 3 residents reviewed for pressure ulcers (Resident #181).

Inspectors wroteBased on record review, resident interview, staff interview, and physician interview the facility failed to assure it administered significant medications on days when a resident had outside physician appointments. This was for one (Resident # 1) of two sampled residents reviewed for medications.

Inspectors wroteBased on record review, resident interview, staff interview, and physician assistant interview the facility failed to assist with transportation for a resident to receive lymphedema treatment as ordered. This was for one (Resident # 4) of four residents reviewed for social service assistance.