Southbridge Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Southbridge Rehabilitation & Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 10, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, had a history of repeated falls, was assessed by nursing as being at risk for falls, and who required an extensive assist of two staff members during transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during the transfer to maintain his/her safety, in an effort to prevent incidents or accidents resulting in an injury. […]

• Actual harm, isolatedF604Mar 16, 2021

  Based on records reviewed, interviews, and observations, for one of three sampled residents (Resident #1), the facility failed to ensure he/she was treated in a respectful and dignified manner, which included being free from all forms of restraints, when on 3/03/21, Certified Nurse Aide (CNA) #1 physically restrained Resident #1 using a flat bed sheet and bath blanket to restrict Resident #1's movements and limit his/her access to his/her legs and suprapubic catheter (a tube inserted through the stomach into the bladder, used to drain urine). Resident #1 sustained redness of the knees, documented as friction-related from Resident #1's legs repeatedly rubbing against the flat bed sheet that had been used to restrain him/her. […]

• No harm, potential for more than minimal, patternF712Apr 3, 2026

  Based on interviews, and record review, the facility failed to ensure one Resident (#107) out of a total sample of 26 residents, was seen by a Physician at the required regulatory frequency for physician visits.Specifically, the facility failed to ensure Resident #107 was seen by a Physician:-for the Resident's initial visit following admission to the facility.-for alternating visits with the Nurse Practitioner (NP) every 30 days for the first 90 days following admission to the facility.-for alternating visits with the NP every 60 days, after the Resident was in the facility for 90 days. Findings include:Resident #107 was admitted to the facility in October 2025 with diagnoses including Chronic Respiratory Failure, Heart Failure, and Hypertension. […]

• No harm, potential for more than minimal, patternF584Dec 18, 2024

  Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two Residents (#55 and #37) and on three units (Second Floor, Third Floor and Forth Floor) out of three total units observed. Specifically, the facility failed to: 1. maintain comfortable water temperatures for bathing in resident rooms and unit shower rooms, resulting in Resident #55 and #37 not receiving showers as desired and requested due to cold water temperatures. 2. […]

• No harm, potential for more than minimal, patternF656Dec 18, 2024

  Based on observation, record review, and interview, the facility failed to implement the comprehensive person-centered plan of care for two Residents (#88, #104) out of a total sample of 26 residents. Specifically, the facility failed to: 1. For Resident #88, implement the fall risk intervention for non-skid strips to the Resident's bedside and bathroom placing the Resident at risk for falls and injury. 2. For Resident #104, implement the nutritional risk intervention for a lip plate with meals placing the Resident at risk for calorie deficit. […]