Southwestern Manor Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Southwestern Manor Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 21, 2023

  Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 93 residents (Resident R1). Findings include: A review of the State Operations Manual (SOM) defines elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge. […]

• Actual harm, patternF684Jun 13, 2024

  Based on review of facility policies clinical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure that residents received care and treatment by failing to identify signs and symptoms of constipation in one of five residents reviewed (Resident R28), resulting in actual harm by admissions to the hospital and failed to provide prescribed treatment and services related to the care of wounds for four of six residents (Resident R4, R11, R12, and R29). Findings include: Review of the facility policy Bowel Regimen Protocol dated 11/30/23, indicated the following will be instituted for constipation: (1) bowel movements are to be recorded by nursing staff in the electronic health care record. […]

• Actual harm, isolatedF600Jun 13, 2024

  Based on review of facility policies and documents, clinical records and documentation, and staff interviews, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R2), that resulted in actual harm of a low leg skin tear. Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. Freedom from Abuse, Neglect, and Exploitation defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF686Jun 13, 2024

  Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for four of seven residents (Resident R1, R12, R13, and R14) and failed to prevent avoidable pressure ulcer development that resulted in the actual harm of a new pressure ulcer for one of seven residents (Resident R1). Findings include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality's, Safety Program for Nursing Home: On-Time Pressure Ulcer Prevention dated May 2016, indicated that Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer hospital stays and increased morbidity and… […]

• Actual harm, isolatedF689Jun 13, 2024

  Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from injury that resulted in actual harm of a lower leg skin tear for two of four residents (Resident R2 and R10). Findings include: Review of facility policy Safety and Supervision of Residents date d 11/30/23, indicated that, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of facility policy Activities of Daily Living (ADL), Supporting dated 11/30/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. […]