Southmont of Presbyterian Seniorcare

In the surveyor’s words

From the most serious findings on record at Southmont of Presbyterian Seniorcare, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 25, 2026

  Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance during care to prevent accidents which resulted in actual harm of a nondisplaced nasal bone (nose) fracture for one of five residents (Resident R1). This was identified as harm for past non-compliance.Findings include: Review of the facility policy Fall Risk Assessment Policy dated 11/21/25, indicated it is the policy of Presbyterian Senior Care Network to provide a safe environment. Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]

• Actual harm, isolatedF600Nov 12, 2025

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a left distal fibula (lower leg above the ankle) fracture for one of five residents reviewed (Resident R1). This was identified as harm for past non-compliance.Findings include: Review of facility document entitled, Corporate Compliance-Abuse Neglect dated 11/20/24, revealed neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Nov 12, 2025

  Based on review of facility policies and documents, clinical record reviews, and staff interview, it was determined the facility failed to provide adequate supervision during transfer to prevent injury which resulted in the actual harm to Resident R1 of a leg fracture for one of five residents. This was identified as harm for past non-compliance. Findings include: Review of facility policy titled, Skilled Nursing-Lifting and Transferring Residents dated 11/20/24, revealed the facility will minimize the risk of injury to residents and transfer residents as safely as possible. Physical therapy will evaluate and recommend transfer status and the physician will obtain an order specifying resident transfer status. […]

• Actual harm, isolatedF689May 31, 2024

  Based on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to implement effective safety measures by not providing hot liquids in a manner that promotes safety for one of four residents reviewed (Resident R78), which resulted in actual harm of a second degree burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for past non-compliance for one resident (Resident R78). Findings include: Review of the facility policy Investigating Adverse Events last reviewed, November 2023, indicated the facility will implement measures for residents at risk for accidents to prevent serious injury when possible. […]

• Actual harm, isolatedF689Jun 30, 2022

  Based on review of the facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide necessary supervision and an environment free of accidental hazards, to ensure that hot liquids were not accessible, resulting in actual harm for one of four Residents (Resident R47). Findings include: Review of facility policy Skilled Nursing-Adverse Events, dated 1/2020, indicates definitions: Adverse event: unexpected occurrence that resulting in serious injury or loss of customer satisfaction. […]