Southpointe Healthcare and Rehabilitation

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Resident (R)1, for one of three sampled residents reviewed for behaviors, and for R11, for one of three residents reviewed for skin conditions. Failure to code the MDS correctly has the potential to lead to inaccurate assessments and care planning of the resident. Findings Include:Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025 revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. [...]

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure a resident received a required Level II PASARR evaluation, for 1 of 4 residents reviewed. Specifically, Resident (R)3 was identified through the Level I PASARR screening as requiring a Level II evaluation; however, the facility did not maintain documentation showing that the Level II PASARR had been completed. This failure had the potential to result in the resident not receiving necessary specialized services or an appropriate level of care.

Inspectors wroteBased on review of facility policy, record review, observation, and interview, the facility failed to properly assess Resident (R)1 for the appropriateness of the self-administration of prescription chlorhexidine mouthwash, for 1 of 3 residents reviewed.

Inspectors wroteBased on review of facility policy, record review, observation, and interview, the facility failed to ensure resident health information was properly concealed from unauthorized viewing during a random observation of medication administration.

Inspectors wroteBased on review of facility policy, interview and record review, the facility failed to ensure Resident (R)12's right to be free from misappropriation of resident property by failing to prevent or protect the resident's three rings from being taken without the resident's consent. This deficient practice was identified in 1 of 4 residents reviewed for misappropriation of property.

Inspectors wroteBased facility policy review, observation, and interview, the facility failed to ensure housekeeping chemicals were securely locked and stored outside of resident areas.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure medication was discontinued after the physician's ordered end date. Specifically, the facility failed to remove chlorhexidine mouthwash from Resident (R)1's bedside, for 1 of 3 residents reviewed.

Inspectors wroteBased facility policy review, record review, observation, and interview, the facility failed to ensure medication was properly and securely stored during two random observations.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided nail care to residents unable to carry out activities of daily living (ADLs), which affected 1 (Resident (R)87) of 2 residents reviewed for ADL assistance.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors, which affected 1 (Resident (R)10) of 8 residents reviewed for medication administration.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided food that accommodated residents' food allergies and preferences, which affected 1 (Resident (R)110) of 1 resident reviewed for food concerns.

Inspectors wroteBased on observations, record review, interviews, facility policy and the Department of Health and Human Services Centers for Medicare & Medicaid Services pathway, the facility failed to maintain infection prevention and control practices for 1 of 1 residents reviewed for colostomy care, Resident (R)1.

Inspectors wroteBased on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)1 from mental and verbal abuse for 1 of 3 residents reviewed for abuse. Specifically, 2 (two) Certified Nursing Assistants (CNA)s video recorded their interaction with R1 and posted the video to social media. On 04/12/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/09/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 04/12/24 at 1:19 PM, the facility provided an acceptable IJ Removal Plan. On 04/12/24, the survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. [...]

Inspectors wroteBased on record review and review of facility's weight policy, titled Weighing the Resident, the facility failed to provide documentation that Resident (R)1 had a 5 % or more weight loss with reviews by facility's dietitian regarding nutritional status with recommendations for interventions for 1 of 1 resident reviewed for weight loss.

Inspectors wroteThe facility admitted R70 on 05/23/2023 with diagnoses including, but not limited to, physical debility, muscle weakness, alcoholic cirrhosis of the liver, muscle wasting and atrophy of the left and right hand, chronic pain, alcohol abuse and nicotine dependence. Review on 07/10/2023 at 12:10 PM of the medical record for R70, revealed sign out sheets for leave of absence starting on 06/14/2023 through 07/09/2023. R70 went out to smoke, signing a leave of absence 40 times during that period of time. He only signed back in 16 times. There is no documentation to ensure the smoking supplies were taken from the resident and secured in a locked area or compartment any of the 40 days. On 06/16/2023, R70 signed out, leave of absence at 9:23 AM to smoke and signed back in on 06/16/2023 at 8:20 PM. On 06/19/2023, R70 signed out, leave of absence to smoke and signed back in at 8:00 PM. [...]

Inspectors wroteBased on review of the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure 1 of 4 medication carts and 1 of 1 treatment carts was locked and secured away from ambulating residents. The facility further failed to ensure expired medications were removed from 4 of 4 medication carts, 1 of 2 med storage rooms, and 1 of 1 treatment carts.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure that 1 Resident (R)69 out 3 residents dressings were changed according to the physician's orders. In addition, the facility failed to ensure that the wound care was provided as physician ordered for 1 (R40) of 3 residents reviewed for wound care. Specifically, R40 did not receive wound care on 07/07/2023. Findings Include: A review of the facility's policy, Wound Care Policy and Procedures, revised on 06/01/2015 revealed the cover dressing should have a date, time, and initial on it. [...]

Inspectors wroteBased on review of the facility policy, observations, interviews, and record review, the facility failed to maintain a resident's dignity during meal service for 1 (Resident (R)40) of 6 residents reviewed for dignity.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 2 (Resident (R)69 and R71) of 22 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for R69 for a diagnosis of diabetes and R70 for smoking.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)13 was provided care and services daily related to bathing for 1 of 3 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on review of facility policy, observation, interview, and record review the facility failed to ensure blood glucose was monitored while a resident was prescribed insulin for 1 resident (R69) out of 3 residents reviewed with a diagnosis of diabetes.

Inspectors wroteBased on interviews and record review the facility failed to ensure ongoing communication, assessment of the resident's condition, and monitoring for complications before and after dialysis treatment for 1 Resident (R)72, of 1 reviewed for dialysis.

Inspectors wroteBased on interview and record review, the facility failed to monitor for behaviors and adverse effects for 1 of 5 residents reviewed for unnecessary medication. Resident (R)61 was ordered Seroquel (an antipsychotic medication) 100 mg every evening and 50 mg every day. The facility did not monitor R61 for behaviors the medications were meant to treat or possible adverse effects the medications may have had.

Inspectors wroteBased on review of the facility policy, the package insert for Flonase, observations, and interviews, the facility failed to ensure a medication error rate, during med pass, less than five (5) percent. The med error rate is 19.23%.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the faciliy failed to ensure Resident (R)90, R21 and R46 were free from significant medication errors during medication administration on 07/11/2023.