The Southwood

The facility failed to ensure health care referral and follow-up was completed for a resident, resulting in two missed appointments with outside providers (a podiatrist and an eye doctor). Records and interviews confirmed that scheduled follow-up appointments from previous visits were not attended, and the resident reported a lack of explanation from staff regarding the missed care.

The facility failed to provide adequate supervision for two residents experiencing frequent falls, resulting in one resident sustaining a fractured pelvis and another falling out of a wheelchair. Based on record reviews and interviews, staff were not providing supervision in accordance with the residents' assessed needs and care plans.

The facility failed to provide adequate supervision for residents in accordance with their assessed needs and care plans. Specifically, two out of four sampled residents experienced frequent falls, including one resident who sustained a fractured pelvis and another who fell out of a wheelchair.

The facility failed to provide adequate supervision for a resident with schizophrenia and destructive behaviors. Specifically, the resident was injurious to herself and required assistance with toileting and hygiene that was not properly maintained according to her care plan. Documentation also noted unexplained bruising and inappropriate behaviors that went unaddressed by staff supervision.

The facility failed to provide adequate supervision for a resident with schizophrenia and destructive behaviors. Specifically, the resident was injurious to herself and required assistance with toileting and hygiene that was not properly maintained according to her care plan. Documentation also noted unexplained bruising and aggressive behavior patterns.

The facility failed to provide adequate supervision for a resident with schizophrenia and destructive behaviors, leading to self-injury and property damage. Specifically, there was no documentation explaining how the resident sustained facial bruises, and the facility failed to monitor changes in behavior and physical safety effectively.

The facility failed to maintain the minimum required number of staff members present at all times to meet the needs of residents in the Assisted Living unit. This failure constitutes a Type B violation regarding staffing adequacy.