Southpointe Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Southpointe Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 12, 2023

  Based on interview, observations, record review and review of facility policies the facility failed to protect 3 of 4 sampled residents from accidents and/or accident hazards, Residents (R)99, R70 and R71. On 07/10/23 at 1:25 PM, the Administrator was notified that the facility's failure to protect residents from accidents and/or accident hazards by allowing R99, R70 and R71 to sign out of the facility to smoke and not signing back in the allowing the facility to not having the knowledge of knowing were the residents are located. Furthermore, a vaporizer (inhalation device) was discovered in the possession of R99. Administrator was notified that the allegations constituted Immediate Jeopardy (IJ) at F689, with an effective date of 06/14/23 and the IJ template was presented. […]

• Immediate jeopardy, isolatedF600Apr 12, 2024

  Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)1 from mental and verbal abuse for 1 of 3 residents reviewed for abuse. Specifically, 2 (two) Certified Nursing Assistants (CNA)s video recorded their interaction with R1 and posted the video to social media. On 04/12/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/09/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 04/12/24 at 1:19 PM, the facility provided an acceptable IJ Removal Plan. […]

• No harm, potential for more than minimal, widespreadF761Jul 12, 2023

  Based on review of the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure 1 of 4 medication carts and 1 of 1 treatment carts was locked and secured away from ambulating residents. The facility further failed to ensure expired medications were removed from 4 of 4 medication carts, 1 of 2 med storage rooms, and 1 of 1 treatment carts. The findings included: Review of the facility's policy titled, Medication Storage, revealed Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2021

  Based on observation, interview, and review of facility policies, the facility failed to prepare food under sanitary conditions. Specifically, equipment was found to have paper and food remnants on it. Dust and/or a black substance was observed in multiple locations in the kitchen. The failure to prepare food under sanitary conditions had the potential to affect 110 residents who consumed food prepared in the kitchen, out of a total of 113 residents residing in the facility at the time of the survey. Findings include: On 08/24/21 at 9:20 AM, an initial tour of the kitchen was conducted with the Kitchen Manager. Observation of the can opener revealed food particles and paper remnants on the blade. […]

• No harm, potential for more than minimal, patternF686Jul 12, 2023

  Based on interview, observation, and record review the facility failed to ensure that 1 Resident (R)69 out 3 residents dressings were changed according to the physician's orders. In addition, the facility failed to ensure that the wound care was provided as physician ordered for 1 (R40) of 3 residents reviewed for wound care. Specifically, R40 did not receive wound care on 07/07/2023. Findings Include: A review of the facility's policy, Wound Care Policy and Procedures, revised on 06/01/2015 revealed the cover dressing should have a date, time, and initial on it. […]