Southfield Wellness Community

In the surveyor’s words

From the most serious findings on record at Southfield Wellness Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 27, 2026

  Based on clinical record review, staff interviews, camera/video footage review and policy review, the facility failed to provide adequate supervision and operational alarm safeguards to prevent the elopement for 1 of 1 resident reviewed (Resident #7). On 7/17/26 at 3:45 PM, Resident #7 exited the building unattended. At 3:46 PM, Staff F, Dietary Staff member entered the lobby and shut off both the door alarm and wander guard alarm (across 2 separate keypads) without investigating the cause or checking the exit. Another resident (Resident #12) asked Staff G, Certified Medication Aide (CMA) if she was going to get Resident #7 who went outside. At 3:50 PM, Staff G, CMA asked staff via walkie-talkie if anyone saw Resident #7. […]

• Actual harm, isolatedF684Dec 4, 2024

  Based on observations, interviews, and record review, the facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning to its original position for 1 out of 3 residents reviewed (Resident #2). Resident #2 required intervention at the Urology Clinic to reduce paraphimosis (foreskin pulled back but unable to return to its original position over the head, or glans, of the penis) on 3 different occasions. This facility reported a census of 52 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE], listed an admission from an acute hospital stay on 9/24/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. […]

• Actual harm, isolatedF690Dec 4, 2024

  Based on observations, interviews and record review, the facility failed to follow standards for bladder care and services for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 had a voiding trial (trial to see if resident could go without a catheter to drain the urine from his bladder) without measuring output or documenting his output for 1 shift. Resident #2 couldn't urinate on a separate shift and had over 1 liter of urine drained from his bladder. Resident #2 had urethral erosion (tissue breakdown around the urinary meatus, opening at the end of the penis) from a Urinary catheter (tube placed in the urethra to drain urine out of the bladder). […]

• Actual harm, isolatedF686Nov 6, 2023

  Based on observation, interview and record review the facility failed to implement treatment orders for pressure sores for 2 of 3 residents reviewed (Residents #307 and #39). In addition, the facility failed to identify a new skin injury for 1 of 3 residents (Resident #307). Resident #307 admitted to the facility on [DATE] with 2 skin injuries but the facility failed to get him treatment orders until 10/30/23. On 11/1/23 staff found Resident #307 with 2 additional areas of concern. Resident #39 had a chronic ulcer on his sacrum and saw a wound specialist on 10/25/23. […]

• Actual harm, isolatedF689Nov 6, 2023

  Based on observation, interview, and record review the facility failed to keep residents safe from accidents and hazards for 4 of 4 residents reviewed (Resident #7, #28, #1, and #11). Staff failed to use a gait belt or ensure proper footwear use when transferring Resident #7. Resident #7 fell on her way to the bathroom and sustained a major injury. After Resident #28 fell , the staff failed to complete neurological assessments. During an observation of a transfer of Resident #1, staff failed to use a gait belt. After Resident #11 sustained a foot injury while off campus, the facility failed to complete an incident report. Findings include: 1. […]