South Shore Rehabilitation

In the surveyor’s words

From the most serious findings on record at South Shore Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 9, 2025

  Based on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death.Based on interview and record review the facility failed to assess, monitor, identify and intervene promptly for one resident (R2) who was responsive but became unresponsive. This failure resulted in R2 being sent to the hospital and led the R2's death.Findings include:The immediate jeopardy began on [DATE], when R2 had a change of condition was not immediately addressed. […]

• Immediate jeopardy, isolatedF600Jan 26, 2024

  Based on interviews and record reviews, the facility failed to follow their abuse policy by failing to ensure resident was safe from abuse by failing to immediately report an allegation of sexual abuse made by R4 regarding employee (V23/CNA); facility failed to protect R4 from additional abuse/trauma by allowing V23 to continue to work after R4 reported the allegation of sexual abuse to a staff member; failed to protect R4 from harm when she initially reported to CNA, prior to incident on 1/11/24 that she did not want V23 to provide care for her anymore. This affected one resident (R4) of 5 residents reviewed for physical abuse. These failures resulted in V23 re-entering resident's room after R4 made an allegation of sexual abuse against V23. […]

• Immediate jeopardy, isolatedF689Dec 18, 2023

  Based on interview and record review, the facility failed to follow their elopement policy for monitoring a cognitively impaired resident (R2) with severe mental illness, who was assessed to have cognitive impairment, and assessed to be at risk of elopement, failed to have a physician order for unsupervised outside pass, and failed to obtain consent from state guardian to be discharged from facility. These failures resulted in R2 eloping from the facility on 10/10/23. R2 was located at a restaurant 4 miles away from the facility and refused to go back to the facility and facility discharged R2 AMA (Against Medical Advice). This was identified as an immediate jeopardy situation which began on 10/10/23 when R2 eloped from the facility. […]

• Actual harm, isolatedF689Sep 13, 2024

  Based on interviews and record review, the facility failed to follow its policy and properly transfer a resident with a mechanical lift device during a transfer procedure for one (R1) resident out of three residents reviewed for resident safety. This failure resulted in R1 sustaining a fracture of the right knee while being transferred in the facility. Findings include: Face sheet dated 09/12/2024, documents R1 is an [AGE] year-old female with diagnoses not limited to: Osteitis deformans, chronic embolism and thrombosis, hypothyroidism, hyperlipidemia, chronic kidney disease, hypertension, and vitamin D deficiency. R1's MDS (Minimum Data Set) dated 08/20/2024, documents R1 has a BIMS (Brief Interview for Mental Status) of 04/15 indicating R1 is severely cognitively impaired. […]

• Actual harm, isolatedF689Jul 26, 2024

  Based on interviews and record reviews, the facility failed to supervise and use the appropriate shower equipment for one (R147) resident out of a total sample of 36 residents reviewed for falls. This failure resulted in R147 falling out of the shower chair and sustaining a closed nondisplaced fracture of the greater trochanter of the right femur. Findings include: R147's Admission Record documents in part medical diagnoses of dementia, seizures, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side. R147's 5/10/2024 Fall Risk Screen documents in part that R147 is at moderate risk for falls. R147's comprehensive care plan documents in part that R147 has a potential for falls and is at risk for injury from falls (initiated 10/02/2023). […]