Terrabella Southport

The facility failed to respond immediately and in accordance with established policies following a fall involving a resident in the Special Care Unit. Specifically, staff did not follow the required protocol for physician notification and immediate care following the unwitnessed fall incident.

The facility failed to respond immediately and in accordance with its policies following a fall involving a resident in the Special Care Unit. Although the resident was found on the floor on 06/21/25, subsequent documentation showed a delay in medical intervention, resulting in the resident being hospitalized with a broken femur.

The facility failed to provide supervision in accordance with residents' assessed needs and care plans for two residents. Specifically, one resident with a high fall risk was left on the floor for several hours unnoticed, and another resident with a history of aggressive behavior was not properly supervised. Additionally, the facility's supervision policy was unavailable for review during multiple requests.

The facility failed to provide supervision in accordance with assessed needs and care plans for two residents. Specifically, one resident with a high fall risk was not properly supervised during ambulation, and another resident in the Special Care Unit with a history of aggressive behaviors was not adequately supervised.

The facility failed to ensure proper medical referral and follow-up for a resident experiencing shortness of breath, chest pain, and atrial fibrillation. Although EMS was called, the Director of Health and Wellness decided not to send the resident to the hospital and failed to notify the resident's primary care physician. The resident subsequently passed away two days later.

The facility failed to ensure appropriate medical referral and follow-up for a resident experiencing acute symptoms, including shortness of breath and atrial fibrillation. Despite EMS arrival, the Director of Health and Wellness decided not to send the resident to the hospital and failed to notify the resident's Primary Care Physician. This failure to follow established incident response policies occurred prior to the resident's death.

The facility failed to ensure one of five sampled residents was tested for tuberculosis disease upon admission. Specifically, documentation for a required two-step TB skin test was missing, and the Director of Health and Wellness could not locate the complete testing records.

The facility failed to meet the personal care needs of a memory care resident who required monitoring and assistance for showering. The resident, who had Alzheimer's disease, was not receiving the necessary assistance for hygiene as required by their care plan.

The facility failed to ensure that one of five sampled residents was tested for tuberculosis disease upon admission. Specifically, documentation for Resident #2 lacked a recorded read date for the first TB skin test and contained no documentation of the required second step TB skin test.