Southridge Village Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Southridge Village Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 5, 2023

  Based on observation, and interview, the facility failed to ensure 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 contaminating food items for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 94 residents who received meals from the kitchen (total 94) as documented on the list provided by the Dietary Supervisor on 5/2/2023. The findings are: 1. On 05/01/23 at 10:53 AM, Dietary Employee #1 opened the oven to check on food items. She picked up a container of beef base from the shelf above the food preparation table and placed it on the counter. She picked a measuring cup, turned on the sink faucet and obtained water. […]

• No harm, potential for more than minimal, widespreadF880Aug 25, 2022

  Based on observation, interview and record review the facility failed to ensure staff applied proper Personal Protective Equipment prior to entering Isolation/Quarantine rooms, appropriate signage was on resident's door, and isolation doors were closed, when possible, to prevent the possible spread of infection for 3 (Residents 1, 2, 3) sample mix residents. The findings are: a. On 8/24/22 at 1:10 pm, rounds were done on 100 halls, the COVID-19 hall. room [ROOM NUMBER], 105 and 106 with PPE (Personal Protective Equipment) bin outside of door and signage on door stating Droplet Precautions Please wear Gown, Gloves, and mask. Visitors: See nurse before entering room. There are also signs showing donning and doffing of PPE. […]

• No harm, potential for more than minimal, widespreadF812Dec 16, 2021

  Based on observation and interview, the facility failed to ensure food items stored in the freezer and dry storage area were covered or sealed; hot food items were heated to a temperature of at least 135 degrees Fahrenheit (F.) before being placed on the steam table to await service; 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. These failed practices had the potential to affect 70 residents who received meals from the kitchen (total census: 71), as documented on a list provided by the Dietary Supervisor on 12/16/21 at 2:51 P.M. The findings are: 1. On 12/15/2021 at 11:33 a.m., the following observations were made in the walk-in freezer: a. […]

• No harm, potential for more than minimal, patternF756Feb 20, 2026

  Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to ensure the provider documented a rationale for the continuation of psychotropic medications on the Medication Regimen Review (MRR) form for three (Residents #2, Resident #7, and Resident #52) of five residents reviewed for unnecessary medications. The findings include: Resident #2 Review of an Order Summary Report revealed Resident #2 had diagnoses which included depression and anxiety and had an order for psychotropic medication which indicated to give the medication by mouth every six hours as needed for anxiety. […]

• No harm, potential for more than minimal, patternF880Feb 20, 2026

  Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure personal items were not stored in Personal Protective Equipment (PPE) container to prevent contamination of clean PPE for one of four PPE storage cabinets; failed to ensure the door to a biohazard room was secured to prevent access by residents or visitors; failed to ensure staff performed hand hygiene when entering and exiting resident rooms during clean laundry delivery to prevent cross contamination from resident to resident on one of one hall observed during laundry delivery; and failed to ensure staff performed hand hygiene and glove changes during medication administration via a central line to prevent… […]