Southeast Rehabilitation & Skilled Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 30, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, the Facility failed to ensure he/she was free from verbal and mental abuse from a staff member, when Resident #2 and Resident #3 witnessed and reported that Nurse #1 threatened and intimidated Resident #1. On 11/07/23, Resident #1 became upset with Nurse #1 because he/she wanted leave the unit to go down for lunch, but could not go until Nurse #1 checked his/her blood sugar and administered his/her medications, Resident #2 and Resident #3 witnessed as Nurse #1 made a grrrrrr type sound directed toward Resident #1, held both of his fists up and then stated he wanted to punch/hit Resident #1 in the head. […]

• Actual harm, isolatedF689Feb 7, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who diagnoses included left sided hemiparesis (weakness or the inability to move one side of the body) in his/her left upper and lower extremities, and who did not like and asked not to be served hot coffee or hot tea, the Facility failed to ensure he/she was provided with adequate safety measures in an effort to maintain his/her safety to be free from incidents/accidents resulting in an injury. On 1/22/23, Resident #1's breakfast tray included a hot cup of coffee served in a Styrofoam cup without a lid, the Styrofoam cup tipped over and the hot coffee spilled onto his/her left thigh which he/she could not immediately feel due to hemiparesis on that side. […]

• Actual harm, isolatedF607Oct 12, 2022

  Based on policy review, record review, and interviews, the facility failed to ensure staff implemented written policies and procedures for allegations of abuse for one Resident (#35), out of a sample of 33 residents. Specifically, the facility failed to ensure an allegation that staff pulled Resident #35's arm when turning and repositioning which caused pain, said the Resident smelled and inquired about his/her children's whereabouts, resulting in the Resident becoming scared and anxious, was a) thoroughly investigated; and b) the alleged staff member was removed pending an investigation; and c) the incident was reported to the Department of Public Health per the facility's policy. […]

• Actual harm, isolatedF610Oct 12, 2022

  Based on policy review, record review, and interview, the facility failed to ensure staff thoroughly investigated an allegation of abuse, for one Resident (#35), out of a total sample of 33 residents, resulting in the Resident becoming scared and anxious. Findings include: Review of the facility's policy titled, Abuse Prohibition, dated September 2020, included but was not limited to the following: - Every [NAME] facility has the responsibility to ensure each resident has the right to be free from abuse, mistreatment, neglect, exploitation, and misappropriation of his/her property. - It will be the facility's responsibility to identify, correct, and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriation of resident property occur. […]

• No harm, potential for more than minimal, widespreadF838Oct 12, 2022

  Based on Facility Assessment review and staff interview, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources (in-servicing) needed to care for residents. Specifically, the facility failed to: 1.) Identify and address a water management program used to address and mitigate the ongoing concern for Legionella bacteria located in the facility's water system; and 2.) Address the use of graduate nurses for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]