Southbrook Healthcare Center

In the surveyor’s words

From the most serious findings on record at Southbrook Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 28, 2022

  Based on medical record review, review of hospital records, review of fall investigations, staff interviews, guardian interview, and review of facility policy for falls and nurse aide rounds, the facility failed to assess the root cause of falls, failed to identify trends and patterns of falls, failed to assess the appropriateness of added fall interventions, failed to care plan fall interventions, and failed to provide adequate supervision to prevent falls. This resulted in Immediate Jeopardy when Resident #02 had eight falls in six weeks which resulted in a fractured pelvis on 06/17/22, fractured ribs on 06/24/22, and a fall on 07/21/22 where she was found face down on the floor bleeding, was sent to the local hospital where she was subsequently transferred to a level one trauma hospital… […]

• Actual harm, isolatedF689Apr 17, 2026

  THE FOLLOWING SURVEY FINDINGS PERTAIN TO INCIDENCE OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility Self-Reported Incidents (SRIs), staff interview, and policy review, the facility failed to provide adequate supervision and monitoring for residents. This resulted in Actual Harm on 03/06/26 when Resident #12 rolled out of bed onto the floor during incontinence care, resulting in a fracture to his clavicle. This affected one (Resident #12) of three residents reviewed for accidents. The facility census was 89 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/29/26 with diagnoses including end stage renal disease, cerebral infarction, and type two diabetes. […]

• Actual harm, isolatedF686May 27, 2025

  Based on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident skin and failed to identify pressure ulcers until they had reached an advanced stage. This resulted in Actual Harm for Resident #54 who was admitted to the facility with a pressure ulcer to his sacrum, left scapula, and right scapula and developed an additional pressure ulcer to his right gluteal fold which was not identified until it had developed into an unstageable ulcer with slough (nonviable tissue which could impede wound healing) and necrotic (dead) tissue. This affected one (Resident # 54) of two residents reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF730May 27, 2025

  Based on personnel record review and staff interview, the facility failed to ensure annual evaluations were completed for staff. This had the potential to affect all of the residents who resided in the facility. The facility census was 90 residents. Findings include: Review of the personnel file for Certified Nursing Assistant (CNA) #120 revealed a hire date of 10/27/22 with no annual evaluation. Review of the personnel file for CNA #128 revealed a hire date of 08/15/23 with no annual evaluation. Review of the personnel file for CNA #117 revealed a hire date of 07/19/22 with no annual evaluation. Interview on 05/21/25 at 10:09 A.M. with Human Resource Manager (HRM) #153 confirmed annual evaluations were not completed for CNAs #120, #128, and #117.

• No harm, potential for more than minimal, widespreadF812May 27, 2025

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility excluding Resident #52 and #62 who did not eat food from the kitchen. The facility census was 90 residents. Findings include: Observation on 05/18/25 from 08:22 A.M. to 8:52 A.M. with Dietary Manager (DM) #201 revealed the following findings in the kitchen: -The dry storage area contained eleven undated cereal bowls, one container of breadcrumbs open to air, four clear plastic containers of cereal with cloudy sides and residue buildup, one clear plastic container of sugar with cloudy sides, one clear plastic container of flour with cloudy sides, one clear… […]