Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Southbrook Nursing Center during CMS and state inspections, most recent first.
The facility did not follow its policy to complete Criminal Background Checks, Employee Disqualification List checks, and NA Registry verifications before hiring three employees. The personnel files of two CMTs and one LPN showed that these checks were not conducted prior to their employment start dates, contrary to the facility's policy. The Administrator and DON acknowledged the expectation for these checks to be completed before new hires begin work.
A facility failed to complete a significant change MDS assessment within the required 14 days for a resident who was admitted to and later discharged from hospice services. Despite the facility's policy and expectations from the MDS Coordinator and nursing leadership, the necessary assessment was not conducted in a timely manner, leading to a deficiency.
The facility failed to accurately document MDS assessments for two residents. One resident's discharge location was incorrectly recorded as 'home' instead of a hospital, and another resident's urinary incontinence was miscoded despite having an indwelling catheter. Interviews confirmed the expectation for accurate MDS assessments.
The facility failed to follow physician orders for two residents, resulting in missed weekly weight monitoring. One resident with dementia, hypertension, and depression, and another with hypothyroidism, COPD, major depressive disorder, and heart failure, both had orders for weekly weights. However, records showed multiple missed opportunities for obtaining these weights. Staff interviews revealed a process for weight monitoring, but the facility did not consistently adhere to the orders, as confirmed by the administration.
A facility failed to provide a comprehensive discharge summary for a resident discharged to their home. The required documentation, including a recapitulation of the resident's stay, medication reconciliation, and a post-discharge plan of care, was missing. Interviews with the ADON and DON confirmed the absence of these documents, indicating non-compliance with the facility's discharge policy.
The facility failed to maintain sanitary conditions in food storage and distribution, with observations of improper glove use by the Dietary Manager and unsealed food items in the freezer. A cheesecake was served at an incorrect temperature, and a box of corn starch was found open and undated, contrary to facility policies.
The facility did not maintain quarterly QAPI committee meetings with required members, as key personnel like the Administrator and Medical Director were absent from several meetings. The facility's policy requires an interdisciplinary QAA Committee, including the Director of Nursing, Medical Director, and Infection Preventionist, to meet quarterly. Despite invitations, the Medical Director attended only one meeting, and the Administrator acknowledged the meetings' benefits but noted they were not conducted as she would prefer.
The facility failed to maintain infection control practices, as staff did not wear gowns during wound and catheter care for residents with indwelling devices or wounds, and there was a lack of proper signage and PPE availability for residents on enhanced barrier precautions (EBP). Observations showed improper hand hygiene during peri care, and interviews revealed inconsistencies in staff understanding of EBP protocols.
The facility failed to maintain an accurate accounting system for the resident trust fund petty cash, leading to discrepancies in recorded and actual cash amounts. The BOM noted issues with agency staff not consistently counting cash, and interviews with LPNs revealed inconsistencies in the cash counting process. The facility's leadership acknowledged the need for accurate petty cash logs.
The facility failed to maintain a sufficient surety bond for residents' personal funds, as the bond amount was less than required by policy. The Business Office Manager was unaware of the increase in funds and did not adjust the bond accordingly, leading to a deficiency.
Failure to Conduct Required Background Checks for New Hires
Penalty
Summary
The facility failed to adhere to its policies regarding the completion of Criminal Background Checks (CBC), Employee Disqualification List (EDL) checks, and Nurse Aide (NA) Registry verifications prior to the employment start date for three out of ten sampled employees. The facility's policy, revised in July 2023, mandates that all potential employees' names be checked against the state-maintained list of individuals ineligible for employment in long-term care facilities. Additionally, the policy requires that the NA Registry be checked for all new hires, with a printed copy placed in the employee file before the employment date. However, the facility did not complete the NA Registry checks for three employees: two Certified Medication Technicians (CMTs) and one Licensed Practical Nurse (LPN). The personnel files of the three employees revealed that the NA Registry checks were not conducted prior to their hire dates. Specifically, the facility failed to check the NA Registry for CMT N, CMT O, and LPN P, despite their respective hire dates being in 2024. During an interview, the Administrator and Director of Nursing (DON) acknowledged that they would expect the NA Registry to be completed for all new hires before their start date, indicating a lapse in following the established procedures designed to prevent abuse, neglect, and exploitation within the facility.
Failure to Complete Timely MDS Assessment for Hospice Status Change
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was admitted to and later discharged from hospice services. According to the facility's policy and the Resident Assessment Instrument (RAI) Manual, a Significant Change in Status Assessment (SCSA) is required within 14 days of a resident's enrollment in or discharge from hospice services. However, the facility did not complete the required MDS assessment within the specified timeframe for the resident in question. Interviews with the MDS Coordinator, Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that they expected a significant change MDS assessment to be completed whenever a resident starts or stops hospice services. Despite this expectation, the facility did not adhere to the policy, resulting in a deficiency related to the timely completion of the MDS assessment for the resident's change in hospice status.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the accuracy of resident assessments. For one resident, the facility incorrectly documented the discharge location on the MDS as 'home' instead of the correct location, which was a hospital. This resident had been transferred to the hospital for further evaluation due to end-stage renal disease and uncontrolled pain. The incorrect documentation on the MDS did not reflect the resident's actual discharge status, which is a requirement under federal regulations for accurate and standardized assessments. For another resident, the facility inaccurately coded the MDS regarding urinary incontinence. The resident had an indwelling catheter, which should have been coded as 'not rated' for urinary incontinence. However, the MDS was incorrectly coded as 'always incontinent.' This error in coding did not accurately reflect the resident's condition, as specified in the RAI Manual. Interviews with the MDS Coordinator and facility leadership confirmed the expectation that MDS assessments should accurately reflect the residents' current conditions.
Failure to Follow Physician Orders for Resident Weights
Penalty
Summary
The facility failed to adhere to physician orders for two residents, resulting in missed opportunities for monitoring their weights as prescribed. Resident #8, diagnosed with dementia, hypertension, and depression, had a physician order for weekly weights every Wednesday, with instructions to re-weigh if there was a weight change greater than five pounds and to notify the ADON/MD of any weight loss or gain. However, the resident's weight records from September to November 2024 showed multiple missed opportunities for these weekly weights, indicating a lack of compliance with the physician's orders. Similarly, Resident #25, who had diagnoses including hypothyroidism, COPD, major depressive disorder, and heart failure, also had a physician order for weekly weights with similar instructions. The weight records for this resident from July to November 2024 revealed numerous missed opportunities for obtaining the required weekly weights. Interviews with facility staff, including an RN and a CNA, indicated that the process for ensuring weights were taken involved communication between shifts and attempts to weigh residents throughout the day. Despite these procedures, the facility did not consistently follow the physician orders, as confirmed by the facility's administration during an interview.
Failure to Complete Comprehensive Discharge Summary
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for a resident who was discharged to their home. The facility's policy requires a discharge summary to be provided upon a resident's discharge, which should include a recapitulation of the resident's stay, reconciliation of pre-discharge and post-discharge medications, and a post-discharge plan of care. However, the review of the resident's medical record showed that these elements were missing. Specifically, there was no recapitulation of the resident's stay, no reconciliation of medications, and no post-discharge plan of care documented. Interviews with the Assistant Director of Nursing (ADON) and the Administrator and Director of Nursing (DON) confirmed the absence of the required documentation. The ADON was unable to find any discharge summary or notes in the computer system, and the DON stated that they would expect such documentation to be completed when a resident is discharged. This deficiency indicates a failure to adhere to the facility's policy on discharge summaries, potentially impacting the continuity of care for the resident.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and distribution, which could lead to cross-contamination and food-borne illnesses. During an observation, a cheesecake served at the noon meal had a temperature of 64 degrees, exceeding the facility's policy that cold food items must be served at 40 degrees or below. Additionally, the single-door freezer contained unsealed food storage bags labeled as french fries, okra, and chicken strips, which were not in compliance with the facility's policy requiring foods to be covered, labeled, and dated. Furthermore, a box of corn starch was found with its lid and inner bag open and undated. The Dietary Manager (DM) was observed preparing plates of food while wearing the same gloves after touching various surfaces, including scoops, plates, bowls, sliced cheese, and buns, without changing them. This was contrary to the facility's policy that gloves must be changed after touching any contaminated surface. Interviews with the DM, Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that they expected food items to be properly stored, gloves to be changed after touching dirty surfaces, and cold food items to be served at the correct temperature.
Failure to Maintain Required QAPI Committee Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's policy mandates that the QAA Committee be interdisciplinary, including the Director of Nursing Services, the Medical Director or designee, at least three other staff members, and the Infection Preventionist. The policy also requires these meetings to occur at least quarterly. However, review of the QAPI meeting sign-in sheets for the past 12 months revealed that key members, such as the Administrator and Medical Director, were absent from meetings on multiple occasions. Specifically, the Administrator and Medical Director did not attend the meetings dated 11/29/24 and 02/01/24, and the Medical Director and Infection Preventionist were absent from an undated meeting. During interviews, the Administrator acknowledged that the Medical Director is invited to meetings and attended one in July, but the sign-in sheet dated 11/29/24 was incorrectly dated and should be 11/29/23. The Administrator expressed that while the meetings are beneficial, they are not conducted as she would prefer. She also stated that she expects the required members, including the Medical Director, Administrator, Director of Nursing, and Infection Preventionist, to be present at all QAPI meetings. This deficiency indicates a failure to adhere to the facility's QAPI policy, potentially impacting the effectiveness of the quality improvement program.
Infection Control Deficiencies in PPE Use and EBP Implementation
Penalty
Summary
The facility failed to maintain proper infection control practices during peri care for two residents and did not implement enhanced barrier precautions (EBP) for four residents. Observations revealed that staff did not follow the facility's policy on EBP, which requires the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. Specifically, staff did not wear gowns during wound care and catheter care for two residents, and there was a lack of proper signage and availability of personal protective equipment (PPE) outside or near the rooms of residents on EBP. During wound care for one resident, an LPN did not wear a gown, and there was no EBP sign or supplies available outside the resident's room. The LPN stated that they would wear gloves for wound care if the patient was not on isolation and would wear a gown and gloves if on contact isolation. In another instance, a CNA did not perform hand hygiene appropriately during peri care for a resident, using the same soiled gloves for multiple tasks and not washing hands between glove changes. Additionally, catheter care for two residents was observed without the use of gowns, and there was no EBP signage or supplies available outside their rooms. Interviews with staff revealed inconsistencies in understanding and implementing EBP, with some staff indicating that gowns were only necessary if there was an infection. The Infection Preventionist and facility leadership acknowledged the expectation for staff to wear proper PPE for residents on EBP, but observations and interviews indicated a lack of adherence to these protocols.
Inaccurate Management of Resident Trust Fund Petty Cash
Penalty
Summary
The facility failed to maintain an accurate accounting system for the resident trust fund petty cash, which had the potential to affect all residents residing in the facility. During a review of the facility-maintained resident petty cash log, a discrepancy was found between the recorded balance and the actual cash on hand. The Business Office Manager (BOM) noted that $100.00 was kept at the nurse's stations for resident access during nights and weekends, but the actual cash count at the nurse's station showed a discrepancy of $5.00. The BOM acknowledged that charge nurses are supposed to count the cash each shift and update the log, but this was not consistently done, especially with agency staff. Interviews with staff revealed inconsistencies in the cash counting process. An LPN reported that the cash count was $65.00 during their shift, but a subsequent withdrawal of $5.00 was not accurately reflected in the log. Another LPN admitted to not counting the money upon starting their shift due to receiving a report and later signing for the count without verifying it. The Administrator, DON, ADON, and Social Services Director confirmed that the petty cash logs should accurately reflect the available funds for residents, indicating a systemic issue in the management of resident funds.
Insufficient Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain a sufficient surety bond for the security of residents' personal funds. The facility's policy required that the surety bond amount be at least one and one-half times the average monthly balance of the residents' personal funds. However, the facility's approved bond amount was $65,000.00, while the average monthly balance of the residents' personal funds was $43,973.75. This average, when multiplied by 1.5, required a bond amount of at least $66,000.00, indicating a deficiency in the bond amount. The Business Office Manager acknowledged during an interview that they were unaware of the increase in the residents' personal funds and did not realize that the bond amount was insufficient. The facility's policy outlined a process for ensuring the bond amount was adequate, which included reviewing the resident trust bank statement and adjusting the bond amount accordingly. However, this process was not followed, leading to the deficiency. The Administrator, DON, ADON, and Social Services Director expressed an expectation that the bond should have been sufficient to cover the residents' funds.
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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 Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Farmington Presbyterian Manor | 0.7 mi | — | 0 | 0 |
| Community Manor | 0.8 mi | — | 1 | 0 |
| Camelot Nursing And Rehabilitation Center | 0.8 mi | — | 7 | 0 |
| St Francois Manor | 2.6 mi | — | 4 | 0 |
| Country Meadows | 6.4 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.