Southwind Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident was safe to perform self-administration of medication for 1 (#25) of 54 sampled residents This deficient practice had the potential to affect a census of 110 Residents. Record review revealed Resident #25 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview for Mental Status) Score was 10 meaning she had moderate cognitive impairment. Record review of Resident #25's medical record revealed the resident did not have an assessment to self-administer her medications. On 09/15/2025 at 9:03 a.m., an observation in Resident #25's room revealed a bottle of Advanced Eye Relief (Over the counter) eye lubricant on her bedside table. Resident #25 stated she used the medication to relieve her dry eyes. She stated she asked her daughter to bring her this medication. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure a safe, clean, and homelike environment for 3 (#79, #88, and #90) out of 5 (#8, #33,#79, #88, and #90) residents investigated for environment. The facility failed to ensure: 1. Wheelchairs were clean for Residents #79 and Resident #90; and 2. The toilet support arm was in good working condition for Resident #88.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was completed for a resident with a planned discharge to the community for 1 (#112) of 3 (#9, #111, and #112) closed records reviewed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident received a nutritional supplement as ordered for 1 resident (#84) of 9 (#1, #11, #23, #30, #55, #72, #84, #89 and #94) residents investigated for dining.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents were provided respiratory care, consistent with professional standards of care for 2 (#61 and $113) of 5 (#8, #49, #61, #108 and #113) residents investigated for respiratory care. The facility failed to:1. Change an empty humidifier bottle for Resident #61, and2. Label oxygen equipment for Resident #113

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 27 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 7.41%. The facility failed to ensure: 1. Resident #8 was administered the correct medication for Guaifenesin ER (Extended Release) as ordered, and 2. Resident #47 was administered Cyanocobalamin as ordered.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles as evidenced by failing to: 1. Discard an expired medication in 1 (Med Cart A ) of 2 (Med Cart A and Med Cart B) medication carts inspected for medication storage; 2. Discard loose tablets in 2 (Med Cart A and Med Cart B) of 2 (Med Cart A and Med Cart B); and3. Properly secure medications for Med Cart C at all times during medication pass.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff used the appropriate portion size serving utensils when serving the lunch meal. Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/14/2025, read in part. 7. Each meal will be checked for: Proper portion sizes. On 09/15/2025 at 12:23 p.m., an observation was made of the food service line during lunch. The red beans and sausage were being served with a green handle spoodle, which was 4 ounces. The okra and tomatoes were being served with a green handle scoop, which equaled to 1/3 cup. A review of the Diet Extensions: Monday, Week 3,. [...]

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (Resident #49) out of 54 sampled residents by failing to ensure the resident's EMAR (Electronic Medication Administration Record) was accurately documented.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident taking an anticoagulant medication was monitored for bruising and/or bleeding for 1 (#1) out of 3 (#1, #2 and #3) residents reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse for 1 (Resident #R1) out of 4 (Resident #1, Resident #2, Resident #3, and Resident #R1) sampled residents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of physical and verbal abuse was reported to the state survey agency no later than 2 hours after the allegation was made for 1 (Resident #R1) out of 4 (#1, #2, #3 and #R1) residents investigated for abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2(#6, and #76) of 5 (#6, #8, #66, #76, and #81) residents sampled for PASARR, out of a total sample of 34 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served in a form to meet individual needs for residents who received pureed diets as evidenced by: 1. Failing to ensure food items were pureed to the appropriate consistency; 2. failing to ensure rice was pureed according to recipe, and 3. failing to ensure regular textured beans and sausage were not placed on Resident #33's meal tray. This deficient practice had the potential to effect the 7 residents who received pureed diets.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the call bell in the resident's room was in reach for 1 (#88) resident. The deficient practice had the potential to effect a census of 101.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all areas or equipment were in good repair as evidenced by failing to ensure a resident's toilet was secured to the floor for 1 (#305) out of 8 (#13, #53, #61, #69, #83, #88, #100, #305) residents investigated for environment.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a person centered care plan for 1 (#100) out of 34 sampled residents, by failing to ensure Resident #100 was care planned for repeatedly pulling her call bell station off the wall. The facility's census was 101.

Inspectors wroteBased on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 1 (Cart #4) of 2 (Cart #1, #4) medication carts observed. The facility had a total of four medication carts.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff provided the appropriate portion sizes according to the recipe for 2 (#33, #97) out of 7 residents who received pureed meals.

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain the recertification of terminal illness for 3 (Resident #1, #2, and #3) out of 6 (Resident #1, #2, #3, #R1, #R2, and #R3) sampled residents reviewed for hospice.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's physician and resident representative (RP) were immediately notified of a change in the resident's condition for 1(#1) of 3 (#1, #2, and #3) sampled residents by failing to notify the physician and RP that the resident had nausea and refused to take her medications in two days.

Inspectors wroteBased on record review, interviews and observation the facility failed to ensure residents remain free from accidents and hazards for 1(#64) out of 4 (#16, #18, #45, #64) residents investigated for falls by failing to secure Resident #64's wheel chair during transportation. This deficient practice resulted in a harm on 08/02/2023 at 4:00 p.m., when Resident #64's wheelchair was not properly secured in the facility's transportation van. The resident's wheelchair flipped backwards and caused the resident to hit her head. Resident #64 was sent to the hospital for evaluation and was diagnosed with a new small acute subdural hemorrhage. Upon completion of evaluation, Resident #64 was transferred from a local hospital to another hospital for a higher level of care. She was hospitalized from [DATE] and returned back to the facility on [DATE]. [...]

Inspectors wroteBased on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#34) of 38 sampled residents. This was evidenced when: 1. Facility staff failed to apply compression stockings. 2. Facility staff failed to place a hand roll in Resident #34's left hand to prevent further contractures; and 3. Failed to apply pneumatic compression device to left leg daily for one hour a day.

Inspectors wroteBased on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 2 (Cart A, B) of 2 (Cart A, B) medication carts observed. The facility had a census of 105 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to assess 1 (#59) resident investigated to self -administer medication out of a finalized sample of 38 residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate.

Inspectors wroteBased on observations, records reviewed and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 2 (#16 and #69) residents investigated out of a finalized sample of 38 residents as evidenced by: 1. Failing to ensure that Resident # 16's MDS (Minimum Data Set) assessment reflected recent falls and the presence of a wander guard (monitoring device) and 2. Failing to identify a PASARR (Preadmission Screening and Resident Review) Level II for Resident #69.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review ) Level I and/or Level II for 1 (#45) of 5 (#34, #37, 45 #77, #95) residents reviewed for PASARR screening out of a total sample of 38 residents.

Inspectors wroteBased on interview and record review, the facility failed to facilitate the resident's, and if applicable, the resident representatives' participation in the care planning process for 3 (#2, #34, #46) of 5 (#1-#5) residents investigated for care planning out of a total sample of 8 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received the necessary treatment and services to promote healing and prevent new ulcers from developing by failing to turn a resident every two hours to prevent development or worsening of pressure ulcers for 1 (#56) out of 3 (#56, #90, #101) residents investigated for pressure ulcers out of a total sample of 38 residents.