Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southview Acres Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
The facility failed to accurately document skin conditions on weekly bath audits for multiple residents with known pressure ulcers, diabetic ulcers, and other wounds. Several residents with documented stage 3 and stage 4 pressure injuries, diabetic foot ulcers, and an abscess were consistently recorded on weekly bath audits as having no new or old skin alterations, despite concurrent wound treatment records. Interviews with RNs and LPNs showed that staff focused on identifying new skin issues during baths or skin checks and often did not record existing wounds, and one RN reported that staff had previously been instructed not to include existing wounds on the audits. No written policy on weekly bath audits was provided, contributing to inconsistent and incomplete medical record documentation.
A resident with moderate cognitive impairment and a history of behavioral issues alleged physical abuse by an LPN after falling out of bed. The facility did not conduct a thorough investigation, as staff and residents from the relevant unit were not interviewed, and the accused LPN was allowed to return to work before the investigation was complete, contrary to policy. This resulted in a failure to protect the resident during the investigation.
A facility failed to follow proper infection control measures during incontinence care for a resident with a suprapubic catheter. Two NAs did not wear gowns as required by Enhanced Barrier Precautions (EBP) signage and failed to adhere to glove use and hand hygiene protocols. They handled soiled materials without changing gloves or sanitizing hands, and one NA handled soiled wipes without gloves. Interviews revealed a lack of awareness and adherence to EBP protocols, despite clear facility policies.
A facility failed to maintain privacy during wound care for a claustrophobic resident who preferred an open door, exposing the resident's wound to the public. Additionally, a patient care sheet with personal information was left unattended on a medication cart in a hallway under construction, potentially affecting multiple residents. Staff interviews revealed a lack of alternative privacy measures and documentation, violating the facility's confidentiality policy.
A resident admitted with intact cognition and multiple medical conditions, including heart failure and diabetes, did not have a comprehensive care conference conducted as required by facility policy. Despite the resident's goal to return to the community and expressed concerns about communication issues, the facility failed to hold a care conference to ensure continuity of care and resident participation in care-planning. Interviews with staff confirmed the absence of documentation for such a meeting.
The facility failed to complete quarterly MDS assessments in a timely and comprehensive manner for two residents. One resident's MDS was incomplete with several sections marked 'In Progress,' while another's MDS had critical sections marked 'Not assessed' due to missing assessments. The registered nurse confirmed these deficiencies, which were not in accordance with the facility's policy on MDS completion and submission timeframes.
The facility failed to develop and maintain comprehensive care plans for two residents, leading to deficiencies in person-centered care. One resident's care plan did not include information about their prosthetic leg, resulting in inadequate staff training and assistance. Another resident's care plan did not reflect their preference to use the toilet, despite their ability to sense the need to urinate. The lack of documentation and staff awareness of the residents' needs and preferences contributed to the deficiencies.
A resident with severe cognitive impairment was observed with long, soiled nails despite being dependent on staff for personal hygiene. The facility's policy required regular nail care, but staff failed to notice or address the resident's condition, and there was no documentation of nail care being provided. Interviews with staff confirmed that nail care should be done on bath days and documented, but this was not adhered to in this case.
A facility failed to reassess and provide activities for a resident on the short-term unit, who expressed interest in activities but was not offered any due to mobility issues and lack of an activities calendar in her room. The resident's care plan lacked specific interventions, and the facility did not have a re-evaluation process for evolving health needs, contributing to the deficiency.
The facility failed to implement comprehensive toileting programs for two residents who were incontinent of bowel and bladder. Despite being cognitively intact and expressing a desire to use the toilet, the residents were not provided with appropriate interventions or trials of toileting programs. Staff interviews and documentation revealed a lack of attempts to offer the use of a toilet or bedpan, leading to deficiencies in care.
A resident received an antibiotic without an end date following hip surgery, leading to prolonged administration. The facility failed to monitor and evaluate the necessity of continued use, resulting in the resident taking a higher than usual prophylactic dose. The infection control preventionist later discovered the antibiotic was intended for only 18 days, highlighting a lapse in communication and oversight.
A resident experienced a delay in diagnosis and treatment for C. diff due to the facility's failure to complete laboratory services. Despite orders for testing, the initial specimen was incorrectly collected, and there was no follow-up on the results. The resident tested positive after a new order was placed.
A resident with dysphagia and other medical conditions was not provided with the ordered nectar-thick liquids, receiving non-thickened drinks instead. The nursing assistant relied on memory rather than checking meal slips, leading to the resident consuming inappropriate liquids and experiencing a wet-sounding cough. The DON confirmed the error, which was against the facility's therapeutic diet policy.
A resident on Enhanced Barrier Precautions had side rails covered with shredded foam, making them unsanitary and difficult to clean. Despite facility policy requiring daily cleaning of hard surfaces, housekeeping staff admitted the foam could not be effectively cleaned. The infection control preventionist confirmed the need for replacement due to the resident's vulnerability.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident reported inadequate dressing and repositioning, while another was observed without required protective devices. The facility failed to implement and document necessary interventions, increasing the risk of pressure ulcers.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
Inaccurate Weekly Skin Audit Documentation for Residents With Known Wounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records, specifically weekly bath/skin audits, for multiple residents with known wounds. For one resident with dementia, bilateral above-knee amputations, vascular disease, and reduced mobility, the MDS indicated no ulcers or skin problems, yet wound documentation showed treatment for a stage 4 pressure ulcer on the right above-knee amputation site between 3/23/26 and 3/25/26. Despite this, the weekly bath audits on 3/17/26 and 3/24/26 either documented only non-tender lymph nodes on the right upper hip or indicated no new or old skin alterations, and did not reflect the existing stage 4 pressure ulcer. Another resident with paraplegia and multiple documented pressure ulcers and wounds, including stage 3 and stage 4 pressure ulcers of the hips, heels, ankle, shin, calf, and medial malleolus, had numerous weekly bath audits over several weeks that consistently indicated no new or old skin alterations. This conflicted with wound documentation showing ongoing treatment for an open lesion on the right Achilles, stage 3 pressure ulcers on the right heel and right medial calf, an unstageable right medial malleolus wound, a left shin wound, and a stage 3 left heel pressure ulcer on multiple dates. Additional residents with diagnoses including malignant neoplasm of the prostate with stage 3 and stage 4 pressure ulcers, type 2 diabetes with skin ulcers and a stage 4 heel ulcer, and end-stage renal disease with peripheral vascular disease and documented pressure ulcers and an abscess, also had weekly bath audits that reported no new or old skin alterations while concurrent wound records showed ongoing treatment for heel ulcers, calf ulcers, toe pressure ulcers, and a coccyx abscess. Interviews with nursing staff revealed inconsistent understanding and practices regarding documentation on weekly bath audits. Several RNs and LPNs stated that during baths or skin checks they look for redness, swelling, open wounds, and other skin issues, and that new findings should be documented on the weekly bath audit, with some indicating they would chart only if there was something new. One LPN stated she would chart “nothing new” if there were no new skin alterations. Another RN stated that any new or existing wound should be noted on the weekly bath audit, but also reported that prior to approximately three months earlier, staff had been instructed not to document existing wounds on these audits. A requested policy on weekly bath audits was not provided, and the lack of clear, consistent documentation practices led to weekly bath audits that did not accurately reflect residents’ known and treated wounds.
Failure to Thoroughly Investigate Abuse Allegation and Protect Resident During Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with moderate cognitive impairment and a history of behavioral issues, including accusations against staff. The resident, who had restless leg syndrome, a history of falls, and impaired safety awareness, made allegations that a staff nurse physically abused him during an incident where he rolled out of bed. Despite the resident's history of making unsubstantiated claims, the facility's policy required a comprehensive investigation, including interviews with all relevant staff and residents, and removal of the alleged perpetrator from resident contact until the investigation was complete. The investigation was incomplete as staff and residents on the unit where the alleged abuse occurred were not interviewed. Only a few nurses and residents from a different unit were questioned, and key staff who had provided care to the resident were not included in the inquiry. The social worker and director of nursing acknowledged that interviews with staff and residents from the transitional care unit (TCU), where the incident allegedly took place, were not conducted. Additionally, the facility's own policy, which mandates thorough documentation and interviews with all potential witnesses and involved parties, was not followed. Furthermore, the staff member accused of abuse was allowed to return to work with resident contact before the investigation was completed, contrary to facility policy. The alleged perpetrator was suspended for only one shift and then returned to duty prior to the conclusion of the investigation. This action failed to ensure the protection of the resident and other vulnerable individuals during the investigation process, as required by both facility policy and regulatory standards.
Infection Control Lapses During Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during incontinence care for a resident who required extensive assistance with personal hygiene and had a suprapubic catheter. The resident's Enhanced Barrier Precautions (EBP) signage indicated that staff needed to wear gloves and gowns during high-contact activities such as changing linens and providing hygiene. However, during an observation, two nursing assistants (NAs) entered the resident's room without wearing gowns, despite the EBP sign and available personal protective equipment (PPE) outside the room. The NAs proceeded with incontinence care, including handling soiled materials and adjusting the resident's bed and linens, without adhering to proper glove use and hand hygiene protocols. The NAs failed to remove soiled gloves, sanitize their hands, and apply new gloves as required by the facility's hand hygiene and EBP policies. One NA even handled soiled wipes without gloves, acknowledging the mistake but attributing it to feeling rushed. Interviews with the NAs revealed a lack of awareness and adherence to the EBP signage and protocols. The infection preventionist and director of nursing confirmed the expectations for gown and glove use, as well as hand hygiene, during personal care for residents on EBPs. The facility's policies clearly outlined the need for hand hygiene before and after resident contact, after glove removal, and when moving between contaminated and clean body sites during care.
Privacy Breach During Wound Care and Exposed Resident Information
Penalty
Summary
The facility failed to maintain privacy during wound care for a resident who expressed being claustrophobic and preferred to keep their doorway open. During an observation, the resident's room door was left wide open while two staff members performed a dressing change on the resident's leg, exposing red-colored tissue and bodily drainage to the public hallway. Despite the resident's preference for an open door, the facility did not assess or offer alternative privacy options, such as portable curtains or repositioning the mobile cart, to ensure privacy for the resident and others passing by. Additionally, the facility did not secure resident identifiable personal care information on a mobile medication cart. A patient care sheet containing personal information was left exposed and unattended on the cart in a hallway where construction workers were present. This oversight had the potential to affect multiple residents whose information was listed on the care sheet. Interviews with staff, including the Director of Nursing and Social Services Designee, revealed a lack of consideration for alternative privacy measures and documentation of such options in the resident's medical record. The facility's policy on confidentiality and personal privacy was not adhered to, as evidenced by the exposed care sheet and the lack of privacy during the resident's wound care.
Failure to Conduct Comprehensive Care Conference for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care-planning process was implemented for a resident, identified as R222, who was reviewed for participation in care-planning. R222 was admitted to the care center with intact cognition and had several medical conditions, including heart failure, diabetes mellitus, and arthritis. The resident's goal was to return to the community, and an active discharge plan was in place. However, the facility did not conduct a comprehensive care conference meeting with R222, which is essential for ensuring continuity of care and promoting resident participation in care-planning. R222 expressed concerns about the lack of communication and the absence of a care conference since their admission. The resident noted that various disciplines, such as nursing, dietary, and therapy, approached them individually rather than in a group setting, which they believed contributed to communication issues. Despite the facility's policy requiring an initial care conference shortly after admission, there was no evidence in R222's medical record that such a meeting had been offered or held. Interviews with facility staff, including the social services designee and the social services director, confirmed the absence of a documented care conference for R222. The staff acknowledged the importance of care conferences in ensuring that services for care are explained and potential barriers to discharge are identified. The facility's policy outlined that social services were responsible for scheduling these meetings, but discrepancies in documentation practices and adherence to policy may have contributed to the oversight.
Incomplete and Untimely MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed in a timely and comprehensive manner for two residents. For one resident, identified as R50, the significant change MDS indicated severe cognitive impairment, hallucinations, and hospice care. However, the subsequent quarterly MDS was incomplete, with multiple sections such as Hearing, Speech and Vision, Behavior, and Bladder and Bowel marked as 'In Progress' and lacking data. The registered nurse confirmed that the MDS was not finished within the required timeframe and that corresponding assessments were also incomplete, leading to sections being marked as 'not assessed.' For another resident, identified as R108, the quarterly MDS was signed as completed, but critical sections like Cognitive Patterns and Mood were marked as 'Not assessed' due to the absence of corresponding assessments such as BIMS and PHQ-9. The registered nurse verified that these sections were not completed because the social services department had not conducted the necessary assessments. The facility's policy on MDS completion and submission timeframes was not adhered to, resulting in these deficiencies.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for two residents, R142 and R139, leading to deficiencies in person-centered care. For R142, the care plan did not include information about the resident's prosthetic leg, despite the resident's need for assistance with ambulation using the prosthetic. Interviews revealed that only a few staff members were trained to assist with the prosthetic leg, and the resident expressed frustration that most staff were not knowledgeable about its use. The care plan and Kardex lacked documentation regarding the prosthetic leg, and there was a lack of coordination in training staff to assist the resident properly. For R139, the care plan did not reflect the resident's preference to use the toilet instead of incontinence pads, despite the resident's ability to sense the need to urinate and express this preference. The care plan also failed to document the resident's fluctuating ability in transfers, as the resident was able to use an EZ stand with assistance during physical therapy sessions. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences and abilities, with staff defaulting to incontinence care without offering the use of a toilet or bedpan. The deficiencies in care planning for both residents highlight a lack of comprehensive, person-centered care plans that reflect the residents' needs and preferences. The facility's failure to update care plans and ensure staff training and coordination resulted in inadequate care for the residents, as evidenced by the lack of documentation and staff awareness of the residents' specific needs and preferences.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to ensure routine personal hygiene care, specifically nail care, for a resident with severe cognitive impairment who was dependent on staff for assistance. The resident, identified as R47, was observed multiple times with long, soiled nails containing debris, despite the facility's policy requiring regular nail care. The resident's care plan did not specify nail length preferences, and there was no documentation of nail care being offered or provided, even though the resident expressed a desire for his nails to be clipped. Interviews with staff, including a nursing assistant and a registered nurse, revealed that nail care should be completed on bath days and could be done in between if needed. However, the staff failed to notice or address the resident's nail condition. The director of nursing confirmed that nail care should be documented and verified by nurses, but this was not done in R47's case. The facility's policy emphasized the importance of nail care in preventing skin problems, yet the lack of adherence to this policy resulted in the deficiency.
Failure to Provide and Reassess Activities for Resident
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions to ensure activities of interest were advertised, offered, and/or provided for a resident (R222) on the short-term unit. Upon admission, R222 was identified as having intact cognition and expressed interest in activities such as reading, keeping up with the news, and engaging in favorite activities. However, the Therapeutic Recreation/Activity Evaluation lacked details on in-room options for these interests, and the care plan did not include specific interventions to address R222's needs. R222, who was initially non-weight bearing due to a leg boot, expressed difficulty in attending activities and noted the absence of an activities calendar in her room. Despite being open to participating in activities, R222 reported that no one offered activities to her. The nursing assistant confirmed that R222 rarely left her room and was not specifically offered activities. The therapeutic recreation coordinator and chaplain acknowledged that activities were not typically programmed on the TCU, and residents were expected to attend activities on other floors. The facility's failure to reassess R222's activity needs after her health improved and to provide in-room activities contributed to the deficiency. The lack of a re-evaluation process for residents with evolving health needs and the absence of a facility activities programming policy further highlighted the deficiency. R222's medical record showed limited participation in activities, and there was no evidence of reassessment to promote her quality of life.
Failure to Implement Toileting Programs for Incontinent Residents
Penalty
Summary
The facility failed to ensure comprehensive assessment and development of interventions for bladder and bowel incontinence for two residents, R142 and R139. R142, who was cognitively intact and had multiple medical conditions including chronic kidney disease and benign prostatic hyperplasia, was always incontinent of bowel. Despite being a candidate for a bowel training program, no trial of a toileting program had been attempted since admission. The care plan indicated interventions such as taking the resident to the toilet upon request and checking every two hours, but these were not effectively implemented. Interviews revealed that R142 often had to wait over an hour to be changed after an incontinent episode, and staff had not monitored or established a bowel schedule for him. R139, also cognitively intact, required substantial assistance with toileting care and was always incontinent of urine. Despite expressing a desire to use the toilet and being able to sense the need to urinate, no trial of a toileting program had been attempted. The care plan lacked evidence of a current or past toileting program, and progress notes did not document any attempts to offer the use of a toilet or bedpan. Interviews with staff indicated that R139 was not offered the toilet or bedpan, and there was no documentation of any toileting schedule attempted during her admission. The facility's policy on bowel disorders indicated that staff and physicians should identify individuals with bowel dysfunction and assess symptoms related to bowel function. However, the facility did not provide a policy on toileting programs when requested. The lack of comprehensive assessment and implementation of toileting programs for residents R142 and R139 led to deficiencies in providing appropriate care for their incontinence needs.
Failure to Monitor and Discontinue Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that a resident's antibiotic regimen was appropriately monitored and evaluated for continued use. A resident, who had intact cognition and no signs of infection, was prescribed 500 mg of cephalexin four times a day for prophylaxis following a hip fracture surgery. The hospital discharge orders did not specify an end date for the antibiotic, and the facility continued administering the medication without verifying the duration of treatment. The resident expressed uncertainty about the necessity of the antibiotic, as she believed it should have been discontinued earlier. The facility's infection control preventionist later discovered that the orthopedic provider intended for the antibiotic to be given for only 18 days. However, due to a lack of communication and oversight, the antibiotic was not discontinued as planned. The physician's assistant, who was not the original ordering provider, was unaware of the antibiotic order and stated that the facility should have contacted him or the hospital to determine an appropriate end date. The facility's failure to track and review the antibiotic order led to the resident receiving a higher than usual prophylactic dose for an extended period, contrary to the facility's Antibiotic Stewardship policy.
Failure to Complete Laboratory Services for C. diff Testing
Penalty
Summary
The facility failed to ensure that an order for laboratory services was completed for a resident who was experiencing symptoms consistent with Clostridium difficile (C. diff) infection. The resident, who was cognitively intact and required assistance with toileting and personal hygiene, had two orders for C. diff testing, one on December 16 and another on December 31. Despite a stool specimen being collected on December 17, the lab informed the facility on December 30 that the specimen was incorrectly collected. A new order was placed, and the resident tested positive for C. diff on January 5. Interviews with staff revealed a lack of follow-up on the initial test results. The licensed practical nurse was unsure of the process if results were not received, and the clinical nurse manager confirmed that the initial specimen was collected in the wrong container. The director of nursing stated that it was expected for nursing staff to follow up with the lab if results were not received within 24-48 hours. The failure to follow up on the initial test led to a delay in diagnosis and treatment for the resident, who had been experiencing diarrhea for about a month.
Failure to Provide Ordered Drink Consistency for Resident
Penalty
Summary
The facility failed to provide the ordered drink consistency for a resident, identified as R82, who was reviewed for dining. R82 had intact cognition and was diagnosed with heart failure, kidney disease, malnutrition, dysphagia, and had a recent diagnosis of RSV and pneumonia. The resident's care plan required a mechanical soft diet with all liquids thickened to a nectar consistency due to swallowing difficulties. However, during an observation, R82 was served non-thickened liquids, including water, coffee, orange juice, and milk, which were not in accordance with the prescribed nectar-thick consistency. The nursing assistant responsible for serving the drinks relied on memory rather than checking the meal slips to determine the correct liquid consistency for residents. This led to R82 consuming non-thickened orange juice, resulting in a wet-sounding cough. The DON confirmed that R82 was supposed to receive nectar-thick liquids and acknowledged the error. The facility's policy required therapeutic diets to be prescribed to support the resident's treatment and plan of care, which was not adhered to in this instance.
Inadequate Cleaning of Resident's Side Rails on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning hard surfaces in a resident's room, specifically for a resident on Enhanced Barrier Precautions (EBP). The resident, identified as R39, had severe cognitive impairment and multiple medical conditions, including an indwelling catheter and pressure ulcers. Observations revealed that the side rails of R39's bed were covered with shredded and broken foam, secured with black tape, making them unsanitary and difficult to clean. Both LPN-A and RN-A confirmed the poor condition of the side rails and their inability to be properly cleaned and disinfected. Interviews with housekeeping staff revealed a lack of consistent cleaning practices for the side rails, despite the facility's policy requiring daily cleaning of all hard surfaces, including bed rails. Housekeepers HK-C, HK-A, and HK-B acknowledged the expectation to clean side rails daily but admitted that the foam covering on R39's side rails was not in good condition and could not be effectively cleaned. The infection control preventionist also confirmed that the foam padding should be replaced as it was not sanitary and could not be cleaned appropriately, especially given the resident's vulnerability and EBP status.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to comprehensively assess, care plan, and implement interventions to prevent recurrent pressure ulcers for two residents with a history of pressure ulcers. One resident, identified as R142, reported having a bed sore on his bottom that was not properly covered with a dressing, and staff only applied cream. The resident expressed concerns about not being repositioned every two hours as required and having to wait too long for assistance when incontinent. Despite having a care plan that included interventions such as applying barrier cream and using a pressure-relieving mattress, there was no consistent documentation of the resident's refusal to turn and reposition, and the care plan lacked a turning and repositioning schedule. Another resident, identified as R39, was observed multiple times without the ordered protection between his knees, both in bed and while seated in a wheelchair. The resident's care plan required a pillow between the knees when in bed and a blue wedge abductor when in a wheelchair to prevent tissue breakdown. However, these interventions were not consistently implemented, as observed during several instances. The nursing staff and practitioners were expected to follow the care plan and kardex for positioning and applying the necessary protective devices, but this was not adhered to, increasing the resident's risk for pressure ulcers. The facility's policy on pressure ulcers and skin breakdown required a full assessment and documentation of pressure sores, including location, stage, and current treatments. However, the facility failed to consistently implement and document the necessary interventions for both residents, leading to the development and recurrence of pressure ulcers. The lack of timely notification to the physician and wound care team further contributed to the deficiency, as immediate action was not taken to address the new pressure areas.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Inver Grove Heights | 0.6 mi | — | 10 | 0 |
| Walker Methodist Westwood Ridge Ii | 1.3 mi | — | 8 | 0 |
| Woodlyn Heights Healthcare Center | 1.4 mi | — | 17 | 0 |
| Cerenity Care Center On Humboldt | 3.2 mi | — | 12 | 0 |
| Shirley Chapman Sholom Home East | 4 mi | — | 0 | 0 |
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