Southridge Rehab & Living Ctr

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to ensure that care plans were developed in the area of comfort care for 1 of 2 reviewed for hospice care (Resident #22), in the area of wandering for 1 of 1 reviewed for elopement (Resident #4), in the area of dialysis for 1 of 1 reviewed for dialysis needs (Resident #6), and in the area of pain for 1 of 1 resident reviewed for pain management (Resident #25).

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#1 , #2 & #3).

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to ensure current provider orders reflected a resident's self-administration of respiratory medication, and failed to complete an assessment of a resident's ability to safely self-administer medication for 1 of 1 residents reviewed for tracheostomy care (R3).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS) Version 3.0 assessments were accurately coded in the areas of Hospice for 1 of 2 sampled residents (Resident #48).

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for tube feeding (Resident #8).

Inspectors wroteBased on observations and interviews, the facility failed to follow professional standards of practice with usage of Personal Protective Equipment (PPE) (Resident #39).

Inspectors wroteBased on interviews, the facility failed to ensure that mail was delivered to all residents on 1 of 6 days, Monday through Saturday. (Saturday)

Inspectors wroteBased on clinical record review, review of the facility's transport policy and interviews, a facility Transportation Aid failed to follow the transport a resident to an appointment safely by not attaching the shoulder harness strap and seat belt resulting in resident sliding from wheelchair during a transport and sustaining a fracture of the left femur for 1 of 3 residents reviewed for facility transports. (#1)Resident #1 was admitted to the facility in March of 2025 following a fall, for rehabilitation and treatment of a fracture of the resident's left distal femur, right proximal humerus, Type 2 Diabetes Mellitus, Atrial Fibrillation, and depression. The fracture of the left distal femur was not healing well, and the resident had an appointment with the Orthopedic Surgeon. During a review of the facility investigation, on 6/26/25, at approximately 8:30 a.m. [...]

Inspectors wroteBased on review of the complaint report, facility internal investigation, clinical record review, facility General Dose Preparation and Medication Administration Policy and Procedure, and interviews, the facility failed to identify the resident prior to administering medications, failed to follow the facilities policy on resident identification resulting in Resident #1 being given another's residents medication resulting in the need for a hospital evaluation for 1 of 1 residents reviewed (Resident #1)

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to provide supervision to a resident after staff found resident in closet in another resident room, with an open window. Resident was previously identified as an elopement risk and had previous exit seeking attempts for 1 of 2 residents identified for elopement risk. Shortly after, the resident was found outside in a snowbank with a second story window open. This failure created an immediate jeopardy situation. (Resident #1)

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the physician when interventions were ineffective in relieving resident's distress. In addition, the facility failed to notify the physician after the resident was missing and required a search to locate or when the resident experienced a life-threatening elopement.

Inspectors wroteBased on record reviews and interviews, the facility failed to follow the baseline care plan implemented for Resident #1 in the area of Behaviors for 5 of 5 days that resident was in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to monitor targeted behaviors to support the use of antipsychotic and antianxiety medications for 1 resident reviewed for unnecessary medications and behavior monitoring.

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair and in sanitary condition for 2 of 2 units.

Inspectors wroteBased on record reviews and interviews, the facility failed to follow the facility Falls Management Policy for 8 of 8 residents reviewed for falls thus far in 2024. Resident (#1,#6, #13,#30, #35, #36, #39 #41,)

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 2 of 2 initial kitchen observations completed on 6/24/24 and 6/25/24. Additionally, the facility failed to ensure that food temperatures were recorded.

Inspectors wroteBased on record reviews and interviews, the facility failed to perform adequate screening and documentation for Pneumococcal and/or Influenza vaccination as required for 2 out of 5 residents screened for vaccinations. (Resident #1, Resident #6)

Inspectors wroteBased on record reviews and interviews, the facility failed to perform adequate screening and documentation for coronavirus (Covid-19) as required for 2 out of 5 residents screened for Covid-19 vaccinations. (Resident #1, Resident #6)

Inspectors wroteBased on record reviews and interviews, the facility failed to provide a call bell to obtain assistance while on the bedside commode for 1 of 3 residents assessed to be a high risk for falls (Resident #1)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure resident's exhibiting symptoms of gastroenteritis were on contact precautions; failed to ensure Personal Protective Equipment (PPE) supplies were available for use (gowns); failed to disinfect resident rooms and common areas with the appropriate (Environmental Protection Agency) EPA cleaner; and failed to educate and reeducate staff on contact precautions and appropriate disinfection resulting in spread of gastroenteritis creating an immediate jeopardy situation to 9 out of 34 Resident's, as of 3/6/2023, on the B2 Unit. (Resident #41, #29, #28, #32, #13, #27, #26, #35, #4). [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement their Antibiotic Stewardship Program (ASP) related to tracking of infections. This has the potential to affect all residents for risk of infection.

Inspectors wroteBased on record review, interviews, and Centers for Medicare and Medicaid Services' (CMS) Corona Virus Disease of 2019 (COVID-19) Long-Term Care (LTC) Facility guidelines, the facility failed to notify resident representatives of resident and/or confirmed positive cases of COVID-19 in a timely manner. This has the potential to affect all residents in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 2 of 2 resident units (A1 and B2). In addition, the facility failed to provide a homelike environment in the area of dining by serving meals on paper products for an extended period of time.

Inspectors wroteBased on record reviews and interview, the facility failed to follow physician orders for 2 of 5 residents reviewed for unnecessary medications (Resident #35, and #13).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 3 medication carts reviewed and failed to ensure that medications were stored properly by having unlocked, unattended medication carts allowing residents and unauthorized persons access to medications, on 2 of 5 days of survey.

Inspectors wroteBased on observations, interviews, and review of the facility's sink/bucket sanitizer form/policy and procedure and review of the food storage policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner, failed to remove expired foods, failed to label and date foods in the walk-in freezer, and failed to monitor the chemical sanitizer levels for the sanitizing buckets for 2 of 5 survey days (3/6/23 and 3/7/23) in the kitchen. This has the potential to affect all residents.

Inspectors wroteBased on observation and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 2 of 3 dumpsters for 3 of 5 days of survey. (3/6/23, 3/7/23, 3/8/23)

Inspectors wroteBased on interview and document review, the facility failed to review and update the Facility Assessment at least annually (between 2017 -2022).

Inspectors wroteBased on interviews and document reviews the facility's Quality Assurance Performance Improvement (QAPI) committee lacked documented attendance of the Administrator and the Medical Director. In addition, the facility failed to present evidence that a quarterly meeting was held 2 of 4 quarters (July 2022 and October 2022).

Inspectors wroteBased on record review and interviews, the facility failed to include a resident in the development of his/her comprehensive plan of care for 1 of 33 sampled residents (#10).

Inspectors wroteBased on record review and interview, the facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (#37).