Southwell Health and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF847Sep 13, 2024

  Based on staff and resident interviews, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R) (R25, R80, R44) reviewed for arbitration agreements had agreements in place that provided the resident/responsible party a period of 30 days to rescind the agreement after it was signed. The facility's arbitration agreement provided a period of 10 days to rescind the agreement which had the potential to affect all residents of the facility. In addition, R80 and R44 had not been educated regarding the arbitration agreements and were not aware the arbitration agreements had been signed by their family members. […]

• No harm, potential for more than minimal, widespreadF848Sep 13, 2024

  Based on staff interview, record review, and review of the facility's arbitration agreement, the facility failed to ensure three of three Residents (R25, R80, R44) reviewed for arbitration had arbitration agreements in place that allowed for a mutually agreed upon arbitrator and venue for arbitration. The facility's arbitration agreement delineated the specific arbitrator that would be used. This deficient practice had the potential to affect all residents in the facility. Findings include: Review of the facility's Conditions of Service and Consent for Treatment located within the Admission Agreement included a section titled Agreement to Alternative Dispute Resolution, which was the facility's arbitration agreement. […]

• No harm, potential for more than minimal, patternF761Nov 30, 2023

  Based on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medication (SHR), the facility failed to ensure that one resident of 18 residents (R15) was administered insulin that was not expired; failed to ensure that one resident of 18 residents (R16) had prescribed Novolog insulin available for coverage; failed to ensure that two of three medications storage room were free of expired medications. The facility census is 80. Findings include, Review of the facility policy Storage of Medication (SHR) dated October 23, 2023, Proacedure: The following procedure is used to store medications: 1. All medications and any components used in their preparation are labeled with the contents, expiration date and any applicable warnings. […]

• No harm, potential for more than minimal, patternF656Oct 27, 2022

  Based on record review and staff interview the facility failed to develop a comprehensive care plan for two residents ((R) R#1 and R#35) receiving oxygen therapy, and the facility failed to develop a care plan for [CONDITION(S)] drug use for one resident R#60. This effected three of 38 sampled residents. Findings include: 1.Record review for R#1 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of orders indicated oxygen at 2 liters per minute (L/M) per nasal cannula routinely. On 10/26/22 at 4:02 p.m. […]

• No harm, potential for more than minimal, patternF758Oct 27, 2022

  Based on interview and record review, the facility failed to ensure [CONDITION(S)] drug use was limited to 14 days unless the physician felt it was appropriate for the as needed (PRN) order to be extended beyond 14 days, documented the rational, and indicated the intended duration for the prn order, for two residents ((R) R#60 and R#81) of five reviewed for unnecessary medications, that had an order for PRN antianxiety medication beyond 14 days. Findings include: 1. Record Review (RR) revealed R#60 admitted facility on 5/31/18, top three diagnoses were Alzheimer's dementia, [CONDITION(S)], Diabetes Mellitus type 2. Additional diagnoses included frailty, generalized anxiety, [CONDITION(S)], bedbound, and cerebral aneurysm-onset 5/16/19. […]