Southfork River Therapy and Living

In the surveyor’s words

From the most serious findings on record at Southfork River Therapy and Living, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 17, 2022

  Based on observation, record review and interview, the facility failed to ensure food items stored in the freezer were covered or sealed and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen according to the list provided by the Dietary Supervisor dated 6/14/2022 at 9:45 AM. The findings are: 1. On 6/13/2022 at 10:26 AM., the following observations were made in the kitchen: a. An opened box of beef patties was stored on a shelf in the freezer. The box was not covered or sealed. b. An opened box of pancakes was stored on a shelf in the freezer. The box was not covered or sealed. c. An opened box of cinnamon roll was stored on a shelf in the freezer. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2021

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were sealed or covered; dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen and expired food items were promptly removed and discarded on or before the expiration or use by dates. These failed practices had the potential to affect 66 Residents who received meals from the kitchen (total census: 68) as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: On [DATE] at 11:18 a.m., an initial tour was conducted with the following observations: a. […]

• No harm, potential for more than minimal, patternF689Sep 8, 2023

  Based on observation, record review, and interview, the facility failed to ensure potentially hazardous chemicals and hygiene products were stored in a secure location on 1 (200 Hall) of 3 (200 Hall, 300 Hall, and 400 Hall) halls to prevent potential access of hazardous items by cognitively impaired residents who ambulate by any means. The findings are: 1. An observation was made on 09/05/23 at 1:27 PM, on a table in the restroom of Resident room [ROOM NUMBER] was an emesis basin with 3 triple blade razors with no covers. On an open shelf mounted on the restroom wall was one small container of mentholated topical ointment, 2 unopened packages and 1 opened package of denture cleanser tablets. 2. […]

• No harm, potential for more than minimal, patternF695Sep 8, 2023

  Based on observation, interview, and record review, the facility failed to ensure a Physicians Order was obtained for CPAP (Continuous Positive Airway Pressure) usage for 1 (Resident #63) of 1 sampled resident who used a CPAP. The findings are: a. On 09/05/23 at 1:28 pm, observed a CPAP mask on Resident #63's nightside, not in a container/bag. b. On 09/06/23 at 9:53 am, observed a CPAP nose piece lying on Resident #63 ' s nightstand, not in a container/bag. c. On 09/07/23 at 2:14 pm, observed a CPAP mask stored in an undated plastic bag. d. On 09/07/23 at 2:43 pm, the Surveyor asked Licensed Practical Nurse (LPN) #2 if Resident #63 had an order for the CPAP. LPN #2 said, I do not see one. e. […]

• No harm, potential for more than minimal, patternF761Sep 8, 2023

  Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals contained a pharmacy label, contained a date opened, and expired medications were removed from the medication cart for 1 or 1 medication room and 2 of 3 medication carts on 2 (100 Hall and 300 Hall). The findings are: 1. On 09/06/23 at 2:41 PM, the following observations were made in the Central Medication Room with Licensed Practical Nurse (LPN) #1: a. An opened box of Acetaminophen Suppositories 650 milligrams with the patient label torn off was in the refrigerator. b. An opened vial of Novolog Insulin with no opened date. c. An intravenous administration set with an expiration date of 09/05/22. d. […]