Southbrook Healthcare, Inc

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 31, 2026

  The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on interview, record review, and facility document and policy review, the facility failed to ensure staff provided the required assistance needed to safely transfer a resident according to their assessed needs, which affected 1 (Resident #41) of 4 residents reviewed for accidents. Specifically, on 02/11/2026, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #41 to the resident's bed on their own, which resulted in the resident being lowered to the ground. […]

• Actual harm, isolatedF684May 3, 2024

  Based on observation, record review, and interview, the facility failed to follow physician orders for wound care for one (#1) of three sampled residents who were reviewed for wound care. Resident #1 was admitted to the hospital for wound dehiscence, cellulitis, and sepsis. The facility reported seven residents in the facility required wound care. The DON reported 61 residents resided in the facility. Findings: The facility's Wound Care policy, dated 10/01/10, read in part, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .The following information should be recorded in the resident's medical record: All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound . […]

• No harm, potential for more than minimal, widespreadF880Sep 14, 2022

  Based on observation and interview, the facility failed to ensure staff performed hand hygiene during the meal pass. The DON reported 49 residents received meals from the kitchen. Findings: On 09/12/22 at 11:45 a.m., CNA #1 was observed in the front dining room, they re- positioned a resident's wheelchair, touched the resident's hand, and served the resident's meal tray without performing hand hygiene. CNA #1 continued to serve multiple meal trays without performing hand hygeine. On 09/12/22 at 11:55 a.m., CNA #1 stated they should have performed hand hygiene prior to each meal tray being served. On 09/13/22 at 10:37 a.m., the DON stated all employees had been inserviced on hand hygiene and CNA #1 should have performed hand hygiene during meal service.

• No harm, potential for more than minimal, patternF584Sep 14, 2022

  Based on observation and interview, the facility failed to provide a home like environment by not maintaining floor tiles. The Resident Census and Conditions of Residents, dated 09/12/22, documented a census of 51 residents. Findings: On 09/12/22 at 10:07 a.m., three broken floor tiles were observed in the center hallway. On 09/12/22 at 10:23 a.m., two broken floor tiles were observed in the dining area. On 09/12/22 at 10:32 a.m., four broken floor tiles were observed in resident room #7. On 09/13/22 at 3:29 p.m., the DON reported the broken floor tiles should have been replaced. On 09/13/22 at 3:30 p.m., the administrator reported the broken floor tiles should have been replaced.

• No harm, potential for more than minimal, patternF761Sep 14, 2022

  Based on observation and interview, the facility failed to ensure narcotics were stored in a permanently affixed compartment. The Resident Census and Conditions of Residents dated 09/12/22, documented 51 residents resided in the facility. Findings: On 09/13/22 at 9:00 a.m., in the medication room refrigerator, narcotic medications were in three plastic sealed bags on refrigerator shelves and inner door shelves. The three plastic sealed bags were not in a locked or secured container, the bags contained: a.16 syringes of [MEDICATION(S)] (an anti-anxiety medication) gel b. 45 syringes of [MEDICATION(S)] (a pain relieving medication) gel c. […]