Southridge Specialty Care

Inspectors wroteBased on observations, interviews and record review, the facility failed to notify 1 resident's family after a fall (Resident #8). The facility reported a census of 71 residents. The facility took corrective action on the day following the fall by providing education to the nurses regarding notifying the family the day that a resident has fallen.

Inspectors wroteBased on clinical record review, staff interviews, policy and Preadmission Screening and Resident Review (PASARR) the facility failed submit a status change in mental health PASRR when 1 of 2 residents (Resident #19) received new mental health diagnoses. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interviews the facility failed follow a physician's order when the failed to arrange a dermatology appointment within a reasonable timeframe for 1 of 2 residents reviewed for wounds (Resident #64). The facility reported a census of 71.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to identify, assess, and put interventions in place for 1 of 1 resident reviewed for undocumented bruises on her body (Resident #8). The facility reported a census of 71 residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the correct diet for 1 resident during a meal service (Resident #39). Resident #1 received a regular textured diet during the meal service. This resident's diet order was for a mechanically soft textured diet. The facility reported a census of 71.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow infection control guidelines for 3 of 3 residents (Residents #24, #45, and #68). 1. During an observation of Staff A, Licensed Practical Nurse (LPN), providing tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, also known as the trachea) care to Resident #45, after she finished the tracheostomy (trach) care, while wearing the same gloves and without completing hand hygiene, she pulled off the dressing over their resident's gastrostomy (surgical hole in the abdomen in which a feeding tube is inserted). Staff A left Resident #45's room with a gown, walked down the hall and returned to the room with tape while still wearing the gown. 2. Witnessed Staff A provided a wound dressing change on Resident #68. [...]

Inspectors wroteBased on observation, record review, facility policy review, resident, staff, and physician interviews, the facility failed to thoroughly assess and follow through on interventions to maintain Resident #1's highest practical physical well being and function for 1 or 5 residents reviewed (Resident #1). Resident #1 experienced unnecessary pain, due to grossly decayed and non-restorable teeth. Resident #1 reported mouth pain in July 2024. She saw a dentist in August 2024. The dentist referred her to the University dental office at her appointment on 8/16/24. The facility failed to arrange an appointment. Resident #1 continued to have oral pain and saw the dentist again on 9/4/24. At this time, the dentist ordered to send Resident #1 to the University Hospital Emergency Room. On 9/8/24, Resident #1 experienced a change in mental status, difficulty breathing, and heart irregularities. [...]

Inspectors wroteBased on observation, resident and staff interviews, and facility assessment review, the facility staff failed to consistently answer call lights within a reasonable amount of time, within 15 minutes, for 2 of 2 nursing units. The facility reported a census of 72 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure accurate records for the administration of controlled substance medications for 1 of 6 residents (Resident #8) reviewed for medication administration. The facility reported a census of 72.

Inspectors wroteBased on record review, resident, staff and physician interviews, and policy review, the facility failed to schedule routine and emergency dental service appointment for 2 of 3 residents reviewed for dental concerns (Resident #1 and #3). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, staff, resident and physician interview along with the facility policy/procedure, the facility failed to prevent a significant medication error from occurring. On 9/16/24, during the morning medication pass, a Certified Medication Aide took Resident #1 and Resident #2 oral medications in clear plastic medication cups into the room in one hand and proceeded to sit down Resident #2 medications on the bedside table and then proceeded to go to Resident #1 bedside table and sat them down. Resident #1 received Resident #2 medications for which resulted in Resident #1 becoming lethargic and difficult to arouse during a morning activity. This warranted an intervention from the physician and ultimately Resident #1 was sent to the nearest emergency room and was admitted with adverse effect of drug, hypoglycemia (low blood sugar) and lethargy. [...]

Inspectors wroteBased on clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to provide needed services in accordance with professional standards for 1 of 4 residents reviewed for assessment and intervention (Resident #11). The facility identified a census of 68 residents.

Inspectors wroteBased on observation, resident and staff interviews, the Payroll Based Journal (PBJ) Staffing Report, and policy review the facility failed to maintain staffing levels to consistently answer call lights within a reasonable amount of time for 5 of 24 residents reviewed for staffing (Residents #24, #30, #32, and #56). Residents and staff reported low staffing caused delayed cares. The facility reported a census of 73 residents.

Inspectors wroteBased on observation, clinical record review, policy review, staff and resident interviews, the facility failed to ensure a dignified existence for 2 of 24 residents reviewed by failing to speak to a resident in a respectful and dignified manner (Resident #32) and by placing a resident's disposable incontinent pad in view of others (Resident #21). The facility reported a census of 73 residents.

Inspectors wroteBased on grievance forms, policy review, staff, and resident interviews, the facility failed to make a prompt effort to resolve a grievance related to missing items for 1 of 1 resident reviewed for missing property (Resident #23). The facility reported a census of 73 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interview, and facility policy and procedure review, the facility failed to follow physician orders for 1 of 4 resident reviewed (Resident #3). Resident #3 had orders of daily weights with specific parameters to notify the provider of a 3 lbs. (pounds) weight gain in 1 day or 5 lbs. in 1 week. The facility failed to complete daily weights in February and March. In addition, the facility failed to notify the provider when directed parameters were met.

Inspectors wroteBased on observations, record review, policy review, resident, and staff interview the facility failed to ensure the facility had certified and compete staff to transfer residents with the mechanical lift for 1 of 3 residents reviewed (Resident #3). The uncertified aide didn't demonstrate competency prior to using the mechanical lift, completed a resident's transfer, and failed to have Resident #3 wear the correct footwear for the transfer as directed on the [NAME]. After the staff eased Resident #3 to the floor, they assessed a skin tear on their right forearm.

Inspectors wroteBased on clinical record review, observations, resident, family and staff interviews, and facility policy review, the facility failed to prevent a male resident (Resident #2) from inappropriately touching a female resident (Resident #1). The facility reported a census of 76 residents Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and with the following diagnoses: Epilepsy, Intellectual Disabilities and Anxiety Disorder. The MDS also identified Resident #1 required partial/moderate staff assistance with toileting, showers, dressing and personal hygiene and independent with the remaining activities of daily living. [...]

Inspectors wroteBased on clinical record review, family, resident and staff interviews, and facility policy review, the facility failed to report an allegation of abuse in a timely manner to the State Agency for two of five residents reviewed (Residents #1 and #2). The facility reported a census of 76 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and with the following diagnoses: Epilepsy, Intellectual Disabilities and Anxiety Disorder. The MDS also identified Resident #1 required partial/moderate staff assistance with toileting, showers, dressing and personal hygiene and independent with the remaining activities of daily living. [...]

Inspectors wroteBased on clinical record review, resident (Resident #5), family and staff interviews, and facility policy review, the facility failed to update Care Plans for 2 of 3 residents reviewed after an incident when inappropriate behavior occurred (Residents #1 and #2 ). The facility reported a census of 76 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0 out of 15 and with the following diagnoses: Epilepsy, Intellectual Disabilities and Anxiety Disorder. The MDS also identified Resident #1 required partial/moderate staff assistance with toileting, showers, dressing and personal hygiene and independent with the remaining activities of daily living. [...]

Inspectors wroteBased on clinical record review, family and staff interviews and facility policy review the facility failed to administer medications as prescribed for 1 of 3 residents reviewed (Resident #121). The resident was administered 2 doses of Tylenol within minutes, by two different Nursing Staff. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy review, the facility failed to ensure facility staff were providing accurate assessments and timely interventions for 1 of 3 residents reviewed with skin issues (Resident #22). In an observation on 5/16/23, Resident #22 found to have several skin issues. The Skin Observation Assessment for the same day showed Resident #22 with no skin concerns. The facility reported a census of 71 residents. Findings Include: According to the Minimum Data Set (MDS) dated [DATE], Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive ability. The resident identified as totally dependent with help of 2 staff for transfers and toileting. He required extensive assistance with the help of 1 for dressing and hygiene. Diagnoses included: [...]

Inspectors wroteBased on clinical record review, observation, staff interviews and policy review the facility failed to effectively control residents' pain for 2 of 3 residents reviewed (Residents #16 and #66) with pain control issues. The facility reported a census of 71 residents. Findings Include: 1. According to the Minimum Data Set (MDS) dated [DATE] Resident #16 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating intact cognitive ability. The resident identified independent with transfers, toileting and eating and required extensive assistance with help of one for dressing. Her diagnose included spinal cord dysfunction in Chronic Obstructive Pulmonary Disease (COPD) anxiety and diabetes mellitus. The Care Plan for Resident #16 dated 1/18/23 showed that she had chronic pain related to arthritis. [...]

Inspectors wroteBased on observations, staff and resident interviews, clinical record review and facility policy review, the facility failed to accurately document and account for narcotic medications for 1 of 3 residents reviewed (Resident #66). The facility reported a census of 71 residents. Findings Include: In an observation on 5/16/23 at 7:22 AM it was discovered that from 4/28/23 - 5/16/23, 5 staff signatures were missing from the Daily Shift Change Narcotic Count Book. When brought to the attention of the Staff F, Assistant Director of Nursing (ADON), she reported the nurses were expected to count all of the narcotics at shift change and the oncoming and outgoing nurse was to sign the book, indicating that all pills had been accounted for. On 5/16/23 at 7:46 AM, it was discovered that two of the missing signatures from 5/14/23 and 5/15/23 had been filled in by the ADON. [...]

Inspectors wroteBased on observation, staff interviews, clinical record review and facility policy review, the facility failed to accurately document resident records for 1 of 3 residents reviewed (Resident #66). The facility reported a census of 71 residents. Findings Include: In an observation on 5/16/23 at 7:22 AM, it was discovered that from 4/28/23 - 5/16/23, 5 staff signatures were missing from the Daily Shift Change Narcotic Count Book. When brought to the attention of Staff F, Assistant Director of Nursing (ADON), she said that the nurses were expected to count all of the narcotics at shift change and the oncoming and outgoing nurse was to sign the book, indicating that all pills had been accounted for. On 5/16/23 at 7:46 AM, it was discovered that two of the missing signatures from 5/14/23 and 5/15/23 had been filled in by the ADON. [...]