Complete Care at Southpointe

Based upon interview and record review, the facility did not ensure the mandatory staffing data submitted for the fourth quarter of 2025 (July 1- September 31) was accurate based on payroll and other verifiable and auditable data in a uniform format according to specifications established by Centers for Medicare and Medicaid Services (CMS). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 92 residents. Findings include: The facility's Assessment was reviewed, including staffing hours and acuity levels of care being provided. The facility's assessment documented the ratio for staffing needs per resident in the facility and triggered for low weekend staffing for the fourth quarter of 2025. Surveyor reviewed nursing schedules, along with the nurse staff posting hours for that time period and noted that there were no documented trends or gaps in weekend staff coverage. On 3/11/2026, at 12:41 PM, Surveyor interviewed Scheduler-M about the nurse and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of the 97 residents residing in the facility. Certified Nursing Assistant (CNA)-R did not have an up-to-date background check completed within the four-year time frame. Findings include: The facility policy and procedure titled Abuse, Neglect and Exploitation dated 3/2/2026 documents: 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. On 3/10/2026, Surveyor requested from Nursing Home Administrator (NHA)-A the personnel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not store food in accordance with professional standards for food service safety on the unit refrigerators for three of the four units in the facility, potentially affecting the residents residing on 3 units in the facility. *Unit 1 refrigerator was 52 degrees, above the facility determined temperature range. *Unit 2 refrigerator was 34 degrees, below the facility determined temperature range. *Unit 3 did not have a thermometer in the freezer as indicated in the facility policy. An undated bag of opened, unsealed mixed fruit was observed in the freezer. Findings include: The facility policy and procedure titled Monitoring of Refrigerator Temperature dated 5/2025 documents: Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. Policy Explanation and Compliance Guidelines: 1. Logs will be kept at the nurses station for the freezer or refrigerator unit. a. Temperatures will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R62) of 2 residents reviewed abuse, neglect, misappropriation and exploitation was free from misappropriation of funds and possible exploitation.On 10/31/25 the facility was notified by Adult Protective Services of an allegation Certified Nursing Assistant (CNA)-Q had misappropriated R62's funds. Investigation revealed CNA-Q misappropriated funds from R62 using their debit card but also convinced R62 to provide R62 with cash, R62's PayPal account information to link R62's PayPal account to CNA-Q's account, and use of R62's cell phone. Findings include:The facility policy titled Code of Conduct revised 11/2025 documents: Policy: The purpose of this policy is to guide employees with respect to standards of conduct expected by this company as part of its compliance and ethics program. Improper activities could damage the company's reputation and otherwise result in serious adverse consequences. All employees are expected to adhere to acceptable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that 1 (R5) of 7 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.R5 has an active MD order for a left palm guard to be worn. Surveyor observed R5 without a left palm guard in place multiple times during survey. R5's left palm guard was not part of R5's Comprehensive Care plan or Certified Nursing Assistant (CNA) Kardex.Findings include: The facility policy with an implemented date of 1/26 and titled, Range of Motion, document, in part: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. The facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to accurately code the Minimum Data Set (MDS) for three of 26 sampled residents (Resident (R) 23, R27, and R89) reviewed for MDS assessments. This deficient practice increased the potential for missed opportunities of care or services. Findings include: 1. Review of R23's undated admission Record located in the electronic medical record (EMR) under the Profile tab indicated an admission date of 04/01/24 and diagnoses of chronic obstructive pulmonary disease (COPD), pulmonary hypertension and anxiety. Review of R23's quarterly MDS with an Assessment Reference Date (ARD) of 10/08/24, located in the EMR under the MDS tab, revealed the resident was marked No for receiving hospice services. Review of R23's Progress Notes located in the EMR under the Progress Note tab, revealed R23 was receiving hospice services until her passing on 10/15/24. 2. Review of R27's undated admission Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to develop a care plan for one of five residents (R)89) identified for smoking behaviors in the sample of 26. This failure has the potential to place the resident risk for unmet care needs and the inability to meet the maximum practicable level of functioning. Findings include: Review of the facility's policy titled Resident Smoking dated 05/31/23 indicated, .All safe smoking measures will be documented on each resident's care plan . Review of the facility's policy titled Comprehensive Care Plan dated 9/2024 indicated, The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. Review of R89's admission Record located in the resident's EMR in the Profile tab revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 99 residents residing in the facility. *The facility's Water Management Plan (WMP) did not identify the two water fountains (bubblers) as a potential risk for Legionella growth and did not identify appropriate control measures for prevention of Legionella growth in the dead legs of the water fountains (bubblers). Findings include: The facility water management policy, titled, Water Management Program, date revised 07/2023 documented, .3) A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .5) Based on the risk assessment, control points will be identified. The list of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the Facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 96 of 99 Residents that reside at the facility. On 07/26/23, Dietary Aide - JJ was observed touching ready to eat food with contaminated gloves and place the food on plates for residents to eat. Dietary Aide-JJ was observed removing their gloves and re-gloving without washing their hands. Findings include: On 07/26/23, at 11:58 a.m., Surveyor observe Dietary Aide- JJ begin the lunch tray line service that services all residents that eat meals prepared by the facility. Dietary Aide-JJ was observed to don gloves without washing her hands. At 12:00 PM, Dietary Aide-JJ was observed touch a bin with her gloved hands then pick up a plate with the same gloved hand. Dietary-JJ then picked up a large rectangular loaf of dinner rolls that were baked into a solid form with her left contaminated gloved hand, pull 3 dinner rolls off the larger rectangle with her right contaminated gloved hand, place one dinner roll on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure 1 (R11) out of 3 residents reviewed for indwelling catheters received the appropriate care. *R11 was admitted to the facility with an indwelling catheter and three weeks later was transferred to the hospital with a Urinary Tract Infection. Upon return to the facility, the facility did not assess the need for the indwelling catheter nor follow up with urology as recommended in the hospital discharge summary. Two months later in July, R11's catheter became clogged, and the facility was unable to irrigate it. At this point the physician noted R11's hospital discharge instructions and ordered a voiding trial. Findings include: Facility policy entitled, Indwelling Catheter Use and Removal, dated 10/22/23 documented, Policy Explanation: Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination. The use of indwelling catheters for managing incontinence is not appropriate and increase the risk of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R458) of 5 Residents reviewed. R458's physician orders does not include parameters of when to notify the physician if R458 were to have low/high blood sugars. Findings include: The Insulin Pen policy revised 10/22 under policy explanation and compliance guidelines documents 5. Monitor blood sugar as ordered by physician. R458 was admitted to the facility on [DATE] with diagnosis which includes diabetes mellitus. The physician orders dated 7/13/23 documents Insulin Aspart Solution 100 unit/ml (milliliter) (Insulin Aspart) Inject 12 units subcutaneously three times a day related to Type 2 Diabetes Mellitus with unspecified complications. The physician orders dated 7/13/23 documents Insulin Glargine-yfgn Subcutaneous Solution 100 unit/ml (Insulin Glargine-yfgn) Inject 25 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with unspecified complications. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.