Southeast Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Sep 5, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: The City Health Inspector suspended the facilities kitchen license to operate and closed the facility kitchen on 8/31/2021 due to a roach infestation and poor sanitation. This failure resulted in identification of Immediate Jeopardy (IJ) on 9/01/2021 at 6:39 p.m. While the immediacy was removed on 9/05/2021, the facility remained out of compliance at serious potential for actual harm that was not immediate jeopardy with a scope of widespread due to the need to monitor the implementation and effectiveness of its Plan of Removal (POR). […]

• Immediate jeopardy, patternF600Aug 19, 2023

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #1) reviewed for neglect, in that: The facility failed to develop and implement systems to properly treat Resident #1's arterial wound to his left foot great toe from [DATE] until [DATE] which resulted in hospitalization , sepsis, gangrene, necrosis and amputation. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. […]

• Immediate jeopardy, patternF684Aug 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care in that: The facility failed to assess and treat resident #1's left foot great toe when the resident developed a wound to his LLE from [DATE] until [DATE] which resulted in a decline in health, a worsening of the wound including the toe turning black, infection, necrosis, gangrene, sepsis, hospitalization , and amputation. The facility also failed to identify and treat a wound to Resident #1's sacrum. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:31 p.m. […]

• Immediate jeopardy, patternF726Aug 19, 2023

  Based on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 1 of 8 residents (Resident #1) and for 4 of 6 licensed staff (Wound Care Nurse, RN D, LVN B and LVN II) reviewed for competent staff, in that: 1. The facility failed to ensure the Wound Care Nurse had completed training for a license violation and remediation and failed to ensure she was competent to perform skin assessments, wound assessments, obtain and implement physician orders and document her finding in the medical record resulting in Resident #1 becoming septic and the amputation of the resident's big toe. 2. […]

• Immediate jeopardy, isolatedF689Apr 3, 2026

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 14 residents (R #57) reviewed for accident hazards and supervision. The facility failed to monitor R #57 while he was on the secure unit patio. R #57 eloped from the facility between 6:45 p.m. to 7:10 p.m. on 3/29/26 and was found approximately ninety-six feet away from the facility near a busy two-lane road. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 4/2/26 at 5:00 p.m. […]