Southshore Health Care Center

Inspectors wroteBased on interviews and records reviewed, for three of four sampled residents (Residents #1, #3 and #4), who had court appointed legal representatives or health care agents, the Facility failed to ensure it honored requests for copies of medical record information within two working days, when their representatives requested copies of documentation from their medical records verbally and/or through email correspondence, but were not provided with copies in accordance with federal regulations.

Inspectors wroteBased on interviews and records reviewed, for two of four sampled residents (Residents #1 and #3) whose diagnoses included psychiatric disorders, the Facility failed to ensure they received and were provided appropriate Behavioral Health services that addressed and met their mental health needs.

Inspectors wroteBased on interviews and records reviewed, for two of three sampled residents (Residents #1 and #3) the facility failed to ensure it protected and facilitated the resident's right to communicate with individuals and entities external to the facility, when staff failed to answer the Facility telephone on multiple days, leaving the telephone to ring and ring unanswered.

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #4), the Facility failed to ensure they reported an injury of unknown origin to the State Survey agency. On 03/11/26, Resident #4 was observed with an injury of unknown origin and was transferred to the Hospital Emergency Department (ED) for evaluation, however the injury was not reported to their State Agency as required.

Inspectors wroteBased on records reviewed and interviews for one of four sampled residents (Resident #4), who on 03/12/26 was found with an injury of unknown origin (bump on Resident #4's forehead), the Facility failed to ensure they conducted and maintained evidence of an investigation into the injury.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physicians orders included the administration of a controlled substance medication, the facility failed to ensure that medication was properly secured and under direct supervision of nursing staff, when on 01/06/26 after administering him/her the medication, Nurse #1 left the blister pack card containing oxycodone (narcotic medication) unattended in Resident #1's room.

Inspectors wroteBased on document review and interviews, the facility failed to ensure that it maintained an effective pest control program that provided an environment that was free of pests and rodents for the 79 residents residing at the facility.

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon.

Inspectors wroteBased on document review and interview, the facility failed to ensure the attending physician and/or responsible party was notified of changes in a resident's condition for two Residents (#83, #8), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #83, that the physician was notified of a change in mental status, verbalizations of wanting to leave the facility and exit seeking behavior; and2. For Resident #8, to inform the attending physician of a significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for five Residents (#72, #57, #31, #1, #5), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #72, to implement physician's orders to apply palm rip/palm roll to the Resident's left hand; 2. For Resident #57, to implement physician's orders to apply his/her glasses and left upper extremity splint;3. For Resident #31, to implement physician's order for laboratory blood work;4. For Resident #1,a. to reconcile and implement physician's order for enteral tube feeding, andb. to reconcile and implement physician's order for oxygen use; and5. For Resident #5,a. to implement the physician's order for oxygen use, and b. to implement the physician's orders for wound treatments.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide two Residents (#15, #83), out of a total sample of 20 residents, with adequate supervision and effective interventions to prevent avoidable accidents. Specifically, the facility failed:1. For Resident #15, to develop and consistently implement effective interventions to prevent recurrent falls; and2. For Resident #83, to provide adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement from the facility.

Inspectors wroteBased on the results of 2 of 2 test trays (one breakfast and one lunch meal) and staff and resident interviews, the facility failed to provide residents with meals and drinks that were palatable, attractive, and at a safe and appetizing temperature.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure the main kitchen dry food storage was maintained in a sanitary condition; 2. Follow proper sanitation and food handling practices while thawing chicken to prevent the outbreak of foodborne illness; and3. Ensure the tile flooring in the main kitchen was maintained in a sanitary and safe condition.

Inspectors wroteBased on observations, interview, and records reviewed, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:1. Ensure Transmission Based Precautions (TBP), specifically Isolation Precautions, were implemented as indicated for residents positive for COVID-19;2. Maintain and implement a Water Management Program to mitigate the risks of Legionella;3. Ensure the infection surveillance line lists were complete and accurate;4. Ensure medications were handled in a sanitary manner during administration for one out of two nurses observed; and5. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one Resident (#5), out of a total sample of 20 residents, had their call light accessible and within reach in order to utilize to call for assistance.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy when one Resident (#51), was involved in a resident-to-resident altercation, in a total sample of 20 residents. Specifically, the facility failed to ensure facility staff who were aware of the incident reported the altercation to leadership to allow for reporting, investigating, and implementing measures to prevent potential future altercations.

Inspectors wroteBased on record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure an allegation of abuse was reported timely to the state agency as required.

Inspectors wroteBased on record review and interviews, for one Resident (#51), of 20 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #51, the facility failed to ensure a resident-to-resident verbal altercation was investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize comprehensive care plans for three Residents (#83, #51, and #5), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #83, to develop and implement comprehensive care plans for a change in mental status including delusions and hallucinations and elopement risk;2. For Resident #51, to ensure a comprehensive care plan was developed to address his/her history of thoughts to self-harm; and3. For Resident #5, to ensure a comprehensive care plan was developed to address his/her oxygen therapy usage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#5), out of a total sample of 20 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to the Foley catheter placement on admission to the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with acceptable professional standards for one Resident (#1), out of a total sample of 20 residents. Specifically, the facility failed to ensure Resident #1's inhaler, topical gel, and allergy nasal spray medications were stored securely.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests.

Inspectors wroteBased on document review and interview, the facility failed to encode and transmit discharge Minimum Data Set (MDS) assessments for two Residents (#33 and #71), out of two MDS assessments reviewed.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert and oriented, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 2/24/25, after being found a second time with a vape pen (electronic cigarette is a handheld device consisting of a battery attached to a cartridge filled with a liquid solution that is vaporized and simulates tobacco or marijuana smoking) in his/her possession, the Assistant Director of Nurses (ADON) asked Resident #1 to come to her office, accompanied by two other staff members for a skin check, during which Resident #1 was instructed to and removed his/her upper body clothing items, as part of a strip search.

Inspectors wroteBased on record review and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy with his/her Health Care Agent (HCA) making his/her medical decisions, and had requested a change in attending Physician's for him/her in early October 2024, the Facility failed ensure they honored the residents right to change attending physicians in a timely manner, when the requested was not facilitated until two months later.

Inspectors wroteBased on records reviewed, interviews and observations, for two of two sampled nursing units (Unit #1 and Unit #2), the Facility failed to ensure nursing staff properly secured all medications (prescription and over the counter), when on 12/09/24, the [NAME] Units' medication room door was observed to be open and unlocked, and the East Units' medication room door was found to be unlocked, therefore leaving medications unsecured.

Inspectors wroteBased on record reviews and interviews for three of three sampled residents (Resident #1, #2 and #3), the Facility failed to ensure nursing provided care and services that met professional standards of practice, when upon admission to the Facility, their medications and/or treatments were not accurately reconciled, and as result not all medications and/or treatments were administered in accordance with what was indicated on the Hospital Discharge Summary, as ordered by the physician and in accordance with facility policy.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two units and the kitchen.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response and rationale for response.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean, safe, comfortable, and homelike environment for the residents at the facility, for 2 of 2 nursing units, and throughout areas of the facility used by residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure quality of care was provided, according to facility protocols and professional standards of practice for one Resident (#50), out of 19 sampled residents. Specifically, the facility failed to ensure preventative skin care treatments were implemented, wound care treatments were implemented when a break in the skin was discovered, non-pressure ulcer evaluations were completed weekly and weekly skin checks were completed, and to ensure a care plan was developed and implemented for a non-pressure wound, resulting in worsening of a non-pressure ulcer on the left heel from a split with slight darkness to unstable eschar (type of necrotic (dead) tissue that can develop on severe wounds. Typically dry, black, firm and usually attached to wound bed).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide adequate supervision to minimize the risk of falls for one Resident (#33), out of a total sample of 19 residents. Specifically, the facility failed to ensure that staff accurately assessed the Resident's risk for falls, falls were thoroughly investigated, and interventions were developed and implemented to mitigate the risk of future falls resulting in six falls in five months, one of which resulted in two skin tears and a left hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#50 and #15), out of 19 sampled residents. Specifically, the facility failed: 1. For Resident #50, to assess and monitor a left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) site, to assess and monitor for adverse reactions/complications, to provide ongoing communication between the nursing facility and dialysis facility, to consistently document assessments of the Resident's condition, to obtain weights for physician evaluation, and to develop a comprehensive care plan for dialysis; and 2. For Resident #15, to provide ongoing communication between the nursing facility and dialysis facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident's medication regimen was free from unnecessary medication without adequate monitoring for two Residents (#1 and #25), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the May 2024 Pharmacy Nursing Recommendation was acted upon in a timely manner to prevent Resident #1 was not receiving a weekly double dose of Alendronate (Fosamax-slows bone loss and prevents fractures in osteoporosis) 70 milligrams for five weeks; and 2. For Resident #25, to monitor for signs/symptoms of adverse consequences (i.e., side effects) of a prescribed anticoagulant agent (blood thinner).

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen dry food storage was maintained in a sanitary condition.

Inspectors wroteBased on record review and interview, the facility failed to administer the Influenza and Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and/or document refusal in the medical record and facility policy for three Residents (#33, #50, #55), out of a total sample of five residents. Specifically, the facility failed: 1. For Resident #33, to document refusal of the influenza vaccine in the electronic medical record; 2. For Resident #50, to administer the pneumococcal vaccine after consent had been obtained (4/22/24); and 3. For Resident #55, to administer the pneumococcal vaccine after consent had been obtained (10/22/21).

Inspectors wroteBased on record review and interview, the facility failed to assess, educate, and administer the COVID-19 vaccine and/or booster in a timely manner and/or to document refusal in the medical record for four Residents (#33, #79, #76, and #50), out of five residents sampled. Specifically, the facility failed: 1. For Resident #33, to educate, offer, and administer the COVID-19 vaccine, and document in the medical record consent/refusal; 2. For Resident #79, to administer the COVID-19 vaccine after consent had been obtained (5/1/24); 3. For Resident #76, to educate, offer, and administer the COVID-19 vaccine, and document in the medical record consent/refusal; and 4. For Resident #50, to document refusal of the COVID-19 vaccine in the electronic medical record.

Inspectors wroteBased on interview and record review, the facility failed to promote the rights of one Resident (#26) to leave the facility, in a total sample of 19 residents. Specifically, the facility restricted Resident #26, who was their own responsible person, from leaving the facility with persons of their choice based on a history of substance use disorder.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#71), from a total sample of 19 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure for one Resident (#72), out of a sample of 19 residents that the Resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she preferred. Specifically, the facility failed to inform the Resident of a toxicology screen (laboratory testing for substance use) being obtained.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#72), out of a total sample of 19 residents, was treated with dignity and respect. Specifically, the facility failed to treat the Resident's belongings with respect during a room search.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for potential misappropriation of resident property for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to investigate and report an allegation of a stolen wallet for Resident #15.

Inspectors wroteBased on interviews and record review, the facility failed to ensure potential misappropriation was reported to the Department of Public Health (DPH) no later than 24 hours in accordance with federal guidelines, for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to report an allegation of a stolen wallet for Resident #15.

Inspectors wroteBased on interviews and record review, the facility failed to investigate potential misappropriation of resident property for one Resident (#15), out of 19 sampled residents. Specifically, the facility failed to investigate an allegation of a stolen wallet for Resident #15.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for one Resident (#50), in a total sample of 19 residents. Specifically, the facility failed to ensure the MDS accurately reflected that the Resident had been receiving dialysis treatments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a monthly Medication Regimen Review (MRR) recommendation to obtain an A1c (blood test that measures an average blood sugar level over a period of two to three months) made by the pharmacy consultant was addressed timely and maintained as part of the permanent medical record for one Resident (#8), out of a total sample of 19 residents.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #1) who were assessed by nursing to be at risk for skin breakdown and were assessed to have pressure injuries, the Facility failed to ensure nursing staff adequately assessed, obtained physician's orders for and provided wound care treatments in accordance with professional standards of practice in an effort to promote wound healing, as result there was a delay in treatment for both residents, and Resident #3's pressure injury which was facility acquired, was noted to have worsened.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) due to confusion and an inability to make his/her own health care decisions, the Facility failed to ensure that his/her Health Care Agent (HCA) was fully informed in advance and given information including the risk and benefits of psychotropic medications prior to their use, when Resident#1 was administered antipsychotic medication for approximately two months by nursing, before obtaining his/her HCA's consent to administer the medication.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to: 1. Ensure grievances were addressed in a timely manner for four Residents (#50, #78, #75, and #45), out of a total sample of 20 residents, and 2. Ensure grievance forms were available in resident care and public areas so residents and/or visitors were able to access forms without requesting staff assistance.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee which included the required members at their meetings.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to: 1. Monitor the smoking sessions to ensure cigarettes were being extinguished and disposed of in a safe manner in the smoking area, and 2. Provide ongoing monitoring of water temperature and pressure to ensure residents could comfortably complete their personal care needs.

Inspectors wroteBased on interview and documentation review, the facility failed to ensure concerns identified in the Resident Group meeting were resolved effectively related to call light response, staff using cellular devices during care, limited availability of the day rooms for resident use, access to the social worker, and the need for the facility to provide ice to residents instead of buying ice themselves.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on two of two units. Specifically, the survey team observed: environmental cleanliness concerns in resident rooms which included dirty wall surfaces, wall surfaces in disrepair, broken blinds, missing tiles, dirty vents, and floors in need of washing.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement the weight policy to ensure weights were obtained monthly to monitor for changes for one Resident (#29), out of a total sample of 20 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure functional furniture, which included chairs for the comfort of residents, was provided for two of two units.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the Resident Representative was fully informed in advance and given information necessary to make health care decisions to the extent required by the court for one Resident (#11), from a total sample of 19 residents.

Inspectors wroteBased on observation, policy review, interview, and record review, the facility failed to ensure that services provided met professional standards of quality for two sampled Residents (#30 and #11), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #30, to ensure medications were consumed after being administered, and 2. For Resident #11, to follow consultant recommendations to obtain a blood level of Lithium (a mood stabilizer used to treat bipolar disorder, with a narrow range of safety).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to: 1. ensure the janitorial closet was securely locked, and hazardous items were not easily accessible to all residents, and 2. for two Residents (#3 and #25), out of a total sample of 20 residents, ensure smoking assessments were completed to determine resident capabilities and deficits to determine whether or not supervision was required.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for three Residents (#49, #70, and #11), out of a total sample of 20 residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary environment in one out of one resident unit nourishment kitchens.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the Resident's status for six Residents (#35, #59, #12, #29, #7, and #88), out of 20 sampled residents. Specifically, the facility failed: 1. For Residents #35, #59, #12, #29, and #7, to accurately reflect the Resident's cognition, and 2. For Resident #88, to accurately code the Resident as a discharge to the community.