Southshore Health Care Center

In the surveyor’s words

From the most serious findings on record at Southshore Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 19, 2024

  Based on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #1) who were assessed by nursing to be at risk for skin breakdown and were assessed to have pressure injuries, the Facility failed to ensure nursing staff adequately assessed, obtained physician's orders for and provided wound care treatments in accordance with professional standards of practice in an effort to promote wound healing, as result there was a delay in treatment for both residents, and Resident #3's pressure injury which was facility acquired, was noted to have worsened. […]

• No harm, potential for more than minimal, widespreadF925Aug 27, 2025

  Based on document review and interviews, the facility failed to ensure that it maintained an effective pest control program that provided an environment that was free of pests and rodents for the 79 residents residing at the facility. Findings include: During a tour of the kitchen on 8/21/2025 at 7:56 A.M., the surveyor observed the main kitchen dry food storage area and made the following observations: -On the left side of the room there were multiple shelves of canned goods with a large amount of mouse droppings on top of the cans. During an interview on 8/21/25 at 8:20 A.M., the Food Service Director (FSD) inspected the dry storage area with the surveyor and said the cans of food with rust along the ends and mouse droppings were the emergency food supply. […]

• No harm, potential for more than minimal, widespreadF925Jun 27, 2024

  Based on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two units and the kitchen. Findings include: Review of the Pest Control Program Description indicated the following: -Depending on specific pest concerns there will be variation in control methods used. Methods used will consider the following options in the order listed: -inspection- technicians will inspect relevant areas -sanitation- these needs will always be communicated to you. […]

• No harm, potential for more than minimal, widespreadF585Mar 2, 2023

  Based on interview, document review, and policy review, the facility failed to: 1. Ensure grievances were addressed in a timely manner for four Residents (#50, #78, #75, and #45), out of a total sample of 20 residents, and 2. Ensure grievance forms were available in resident care and public areas so residents and/or visitors were able to access forms without requesting staff assistance. Findings include: Review of the facility's policy titled Grievance Policy, undated, indicated but was not limited to the following: - Residents have the right to voice grievance without discrimination or reprisal or fear of discrimination or reprisal. […]

• No harm, potential for more than minimal, widespreadF868Mar 2, 2023

  Based on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee which included the required members at their meetings. Findings include: Review of the facility's policy titled Quality Performance Improvement, dated 4/2015, indicated but was not limited to: - The Administrator or Staff Development Coordinator shall act as Chairperson for the Quality Improvement Committee and shall be responsible for assuring the minutes are recorded for all meetings. - The full Quality Improvement Committee which included the Medical Director, shall meet at least quarterly. […]