Southbrook Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF698Nov 3, 2023

  Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center for two residents (Resident #24 and #289) out of two sampled residents receiving dialysis. The facility census was 83. Review of the facility's policy titled, Dialysis, dated 03/2023, showed: - Will coordinate and collaborate with local dialysis facilities to meet the resident's nutrition and hydration needs; - Will provide ongoing daily monitoring and care of the resident's vascular access (a way to reach the blood for dialysis); - Will provide ongoing monitoring for dialysis related complications such as bleeding, access… […]

• No harm, potential for more than minimal, isolatedF550Apr 10, 2026

  Based on interview and record review, the facility failed to promote and protect the rights of residents, including the right to make choices regarding dining preferences for two residents (Residents #29 and #86) out of 19 sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 94.The facility did not provide a policy regarding resident dining location and meal choice upon request. Review of the facility's New Hall Tray Menu for Breakfast, undated, showed:-Monday: Biscuits and Gravy, Eggs, Meat;-Tuesday: Eggs, Meat, Toast;-Wednesday: Pancakes, Meat, Eggs;-Thursday: Biscuits and Gravy, Meat, Eggs;-Friday: French Toast, Meat, Eggs;-Saturday: Oatmeal, Toast, Meat, Eggs:-Sunday: Pancakes, Eggs, Meat;-Special Dining Room… […]

• No harm, potential for more than minimal, isolatedF695Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to follow physician's orders for oxygen (O2) use for two residents (Residents #68 and #80) out of seven sampled residents and one resident (Resident #22) outside the sample. The facility's census was 94.Review of the facility's policy titled, Oxygen Administration, undated, showed:- Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control;- The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders;- Staff shall perform hand hygiene when administering oxygen and or when in contact with oxygen… […]

• No harm, potential for more than minimal, isolatedF880Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during perineal (the area between the genitals and the anus) care for one resident (Resident #95) out of one sampled resident and during wound care for two residents (Residents #4 and #37) out of two sampled residents with a wound. The facility's census was 94.Review of the facility's policy titled, Wound Treatment Management, undated, showed: - Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of the dressing change; - The policy did not address infection prevention. […]

• No harm, potential for more than minimal, isolatedF607Nov 22, 2024

  Based on interview and record review, the facility failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) and the Nurse Aide (NA) Registry were completed prior to the employment start date for three employees out of 10 sampled employees. The facility's census was 87. Review of the facility's policy titled, Abuse, Neglect, and Exploitation revised July 2023, showed: - The names of all potential employees will be checked against the list maintained by the State of persons who may not be eligible for employment within a long-term care facility. […]