Southview Acres Healthcare Center

In the surveyor’s words

From the most serious findings on record at Southview Acres Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Aug 18, 2021

  Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to failure to appropriately quarantine residents who had been directly exposed to COVID-19 for 4 of 18 residents (R1, R4, R5, and R6). In addition, failed to implement N95 respirators for 18 of 18 residents (R1, R4, R5, R6, R7, R8, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) who were quarantined due to direct exposure to COVID-19. This resulted in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19. […]

• Immediate jeopardy, isolatedF760Jul 23, 2021

  Based on interview, and document review, the facility failed to ensure [MEDICATION(S)] (a narcotic medication) was administered as prescribed for 1 of 3 residents (R1) reviewed for medication errors. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1 who received a [MEDICATION(S)] dose 20 times greater than was was prescribed, became unresponsive and subsequently died . The IJ began on [DATE], at 11:12 a.m. when R1 was administered 100 milligrams (mg) of [MEDICATION(S)] rather than 5 mg as ordered. R1 became somnolent, had fixed/glazed eyes, and died the following morning. The administrator and director of nursing (DON) were notified of the IJ at 5:27 p.m. on [DATE]. […]

• Actual harm, isolatedF684Mar 26, 2026

  Based on interview and record review, the facility failed to treat a wound when first discovered for one of one resident (R1) when the facility staff identified a wound on 3/16/26, applied a dressing, and then notified the provider and initiated treatment on 3/23/26. Findings include:R1's provider encounter note dated 3/4/26 did not include a skin assessment of R1. R1's minimum data set (MDS) dated [DATE] indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia with other behavioral disturbances. R1's additional diagnoses included vascular dementia without behavioral disturbance, acquired absence of left leg above knee, acquired absence of right leg above knee, vascular disease, and reduced mobility. R1 had no ulcers, wounds, or skin problems. […]

• Actual harm, isolatedF689Feb 7, 2024

  Based on interview and record review, the facility failed to comprehensively assess a resident, reevaluate interventions, or make changes to a care plan after a fall for one of three residents (R1) reviewed for falls when R1 had a previous fall with a history of letting go of the EZ stand lift grab bars. R1's recent fall resulted in fractures of her neck and back. Findings include: R1's admission record printed 2/5/24 stated R1 was initially admitted to the facility on [DATE] to the transitional care unit (TCU) and was transferred to long-term care (LTC) on 3/16/23 with a diagnosis of weakness and anemia. […]

• Actual harm, isolatedF689Jan 12, 2024

  Based on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement appropriate fall interventions to decrease the risk for 2 of 3 residents (R1, R2) with falls. This resulted in harm for R1 who sustained two serious head injuries, was transferred to the hospital, and later died as a result of his injuries. Findings include: Vulnerable adult maltreatment report submitted to the State Agency dated [DATE], identified R1 was discharged from hospital on [DATE] and admitted to transitional care unit (TCU). R1 was readmitted to hospital on [DATE] . R1 was diagnosed with subdural hematoma, subarachnoid hemorrhage, parietal skull fracture, deep tissue injury to left heel, pressure injury to the coccyx. […]