Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of resident council minutes and facility policy, staff and resident interviews, the facility
failed to address resident concerns identified during Resident Council meetings. This affected five (#16,
#27, #41, #63 and #73) of five residents interviewed for concerns and resolutions presented at resident
council meetings. The facility census was 82.
Residents Affected - Some
Finding include:
Interviews on 12/19/19 from 11:08 A.M. to 12:00 P.M., with Residents (#16, #27, #41, #63 and #73)
revealed several concerns were brought up continually to the facility and they stated the issues have not
been resolved. All five residents stated they have asked the facility if a bathroom close to the center of the
building where meals and activities are held, could be designated as a resident restroom, or a staff member
could be available during activities to assist residents to the restroom when needed. All five resident also
identified there were times when they had not received evening snacks.
Review of the Resident Council meeting minutes dated 12/2018 through 11/2019, revealed multiple
concerns were identified by the residents at each meeting. The concern of not having a restroom
designated for the residents close to the center of the building was mentioned by residents in the Resident
Council meetings dated 12/26/18, 01/30/19, 02/27/19, 03/27/19, 06/26/19, 07/31/19, 08/28/19, 09/25/19,
10/30/19 and 11/27/19. The concerns of not receiving evening snacks was identified in the 07/31/19 and
11/27/19 meetings.
Interview on 12/19/19 at 1:17 P.M., with Activities Director #206, confirmed he did not have any written
resolutions to monthly Resident Council meetings. He stated he would tell the involved department head
and they would take care of the problem. He confirmed he didn't know whether the concerns were
corrected unless they told him.
Interview on 11/19/19 at 1:28 P.M., with Dietary Manager #250 confirmed the Activities Director #206 had
told her about evening snacks being a concern that was brought up during Resident Council. She stated
she had discussed the concern with the past Director of Nursing. Dietary Manager #250 confirmed her staff
drops off snacks at each unit, but they do not pass them.
Interviews on 12/19/19 between 1:39 P.M. and 1:45 P.M., with State Tested Nurse's Aides (STNA) #140 and
#187 and Licensed Practical Nurse (LPN) #129 confirmed the dietary department delivered snacks and
would leave the tray on the nursing desk. All three staff confirmed that residents will come up to the tray
and take multiple snacks, and many times there aren't enough snacks to go around. Both STNAs #140 and
#187 stated the STNA's are supposed to pass the evening snacks but many times they do not. LPN #129
stated she tried to monitor the snacks but can not always be present when they arrived.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
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Event ID:
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Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Interview on 12/19/19 at 3:17 P.M., with the Interim Administrator (Int Adm) and the Director of Nursing
confirmed no Resident Council response/tracking forms had been utilized to address any resident concerns
identified during Resident Council meetings. The facility has no documented evidence of resolutions to the
concerns brought up by the residents.
Review of the facility's policy titled Resident Council, dated 04/2017, revealed Resident Council Response
Forms would be utilized to track issues and their resolution.
Event ID:
Facility ID:
365424
If continuation sheet
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Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, policy review and staff interviews, the facility failed to accurately assess residents in
the Minimum Data Set (MDS) assessment. This affected three (#11, #33, and #132) of five residents
reviewed for unnecessary medications. The census was 82.
Residents Affected - Few
Findings include:
1. Review of Resident #33's medical record revealed an admission date of 01/09/18. Diagnoses included
peripheral vascular disease, depressive disorders, kidney failure, and dependence on renal dialysis.
Review of of physician orders revealed an order dated 09/13/19 for Depakene (Depakote) solution 250
milligrams (mg) per 5 milliliters (ml) give 10 ml via gastronomy tube three times a day for seizures.
Review of physician documentation dated 09/24/19 revealed Resident #33 received Depakote three times a
day for seizures.
Review of a quarterly MDS assessment dated [DATE] revealed Resident #33 was not assessed as having a
seizure disorder or epilepsy.
Interview with the Corporate MDS nurse #235 on 12/18/19 at 1:55 P.M., confirmed Resident #33 should
have been coded for a seizure disorder on quarterly MDS date 10/10/19.
2. Review of Resident #132's medical record revealed an admission date of 12/05/19. Diagnoses included
fracture of left leg, osteoporosis, cardiac pacemaker, and hypothyroidism.
Review of medication administration records (MARs) revealed Resident #132 had received enoxaparin
sodium (anticoagulant) 30 mg subcutaneously daily since 12/07/19.
Review of a comprehensive admission MDS assessment dated [DATE] revealed that Resident #132 was
not coded as receiving an anticoagulant medication.
Interview with MDS Nurse #189 on 12/19/19 at 11:24 A.M., confirmed Resident #132 should have been
coded for receiving an anticoagulant medication in the comprehensive admission MDS dated [DATE].
3. Review of Resident #11's medical record revealed an admission date of 05/06/2003, with a readmission
date of 05/29/09. Diagnoses included disorder of the urea cycle, intracranial injury, paranoid schizophrenia,
schizoaffective disorder, bipolar type, unspecified psychosis, major depressive disorder, anxiety disorder,
migraines, chronic pain, neuralgia and neuritis, congenital malformation of the nervous system, unspecified
convulsions and dementia with behavioral disturbances.
Review of the behavior logs for Resident #11, dated 06/01/19 through 12/18/19, revealed the resident did
not exhibit any negative behaviors.
Review of the quarterly MDS assessment dated [DATE], reveled Resident #11 had no cognitive impairment.
He was assessed to have delusions but did not exhibit any physical behaviors symptoms. However,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
he did exhibit verbal behavior symptoms for one to three days. In addition, Resident #11 was assessed to
be taking antipsychotic and antidepressant medications times seven days. Antipsychotic medications were
administered on a routine basis and no gradual dose reductions (GDR) had been attempted. The
assessment documented that a GDR had not been documented by the physician as clinically
contraindicated but 06/20/19 was documented as the date the physician documented a GDR as clinically
contraindicated.
Interview on 12/19/19 at 4:00 P.M. with Corporate MDS nurse #235, confirmed behaviors are documented
by the social worker. She also confirmed the section stated the physician had not documented a GDR was
contraindicated was incorrect.
Interview on 12/19/19 at 4:17 P.M. with Licensed Social Worker (LSW) #209, confirmed she had assessed
Resident #11 for his quarterly MDS assessment, dated 09/16/19. She stated she got the information for his
behavior from the nurses. LSW #209 confirmed she could not find any documentation in the nursing notes
or in the resident's medical record that stated he was currently having delusions.
Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed
the physician was to be a part of the resident's comprehensive assessment.
Review of the facility's policy titled Charting and Documentation, dated 07/2017, revealed documentation in
the medical record would be complete and accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and staff interview, the facility failed to follow a physician order for
dialysis dressing removal. This affected one (#33) of one resident reviewed for dialysis. The census was 82.
Residents Affected - Few
Findings include:
Review of Resident #33's medical record revealed an admission date of 01/09/18. Diagnoses included
peripheral vascular disease, depressive disorders, kidney failure, and dependence on renal dialysis.
Resident #33 was assessed by staff as having moderate cognitive impairment in a quarterly Minimum Data
Set (MDS) assessment dated [DATE].
Review of physician orders revealed and order dated 09/07/19 to take off dialysis dressing every other
evening after dialysis treatment Tuesday/Thursday/Saturday.
Review of treatment administration records (TAR) for December 2019 revealed the removal of Resident
#33's dialysis dressing was documented as being completed on 12/17/19.
Observation of Resident #33's right lower arm fistula on Wednesday 12/18/19 at 10:52 A.M. revealed a
dialysis dressing was in place.
Interview with Licensed Practical Nurse (LPN) #104 on 12/18/19 at 10:52 A.M. confirmed Resident #33's
dialysis dressing was in place on his right lower arm. LPN #104 confirmed it should have been removed the
evening of 12/17/19 after dialysis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observations, medical record review, resident and staff interviews, the facility failed to ensure a
resident's medications were administered and not left at bedside. This affected one (#55) of six residents
observed during medication administration. The census was 82.
Findings include:
Review of Resident # 55's medical record revealed an admission date of 08/04/17. Diagnoses included:
atherosclerosis of coronary artery, muscle weakness, chronic pain syndrome, congestive heart failure,
hypertension, and chronic kidney disease. Resident #55 was assessed as being cognitively intact in a
Minimum Data Set (MDS) dated
Interview on 12/17/19 at 4:43 PM an interview with Resident #55 revealed she was experiencing back pain
and was upset because the nurse wants her to take an anxiety pill for the pain. Resident #55 explained the
nurses bring the anxiety pill to her at bedtime in a medicine cup. When the nurse leaves, she takes the pill
out of the cup and wraps it in a tissue and throws it away in her bed side waste basket. Observation of the
waste basket during the time of interview revealed it to be empty.
Observation on 12/18/19 at 8:57 A.M. revealed Resident #55 was eating breakfast while in her room.
Medications in a small plastic medicine cup were on Resident #55's beside table. A nurse was not in
Resident #55's room.
Interview and observation with Licensed Practical Nurse (LPN) #120 on 12/18/19 at 8:57 A.M. confirmed
she had just administered medications to Resident #55. LPN #120 was standing in the hallway outside of
Resident #55's room beside the medication cart.
Observation an interview with Resident #55 on 12/18/19 at 9:01 A.M., revealed she does not take all of her
medications at once, she takes them while she eats. Sometimes the nurses stay with her , and sometimes
they don't. Resident #55 had four pills remaining in her medicine cup and continued to take them while she
eat her breakfast.
Interview with LPN #120 on 12/18/19 at 9:01 A.M. confirmed she had left Resident #55's medications with
her and had not watched Resident #55 take them all.
Review of Resident #55's Medication Administration record (MAR) revealed 13 different medications in
pill/tablet form were documented as being administered on 12/18/19 at 9:00 A.M. by LPN #120. These
medications were aspirin 81 milligrams (mg), carvedilol 3.125 mg, colace 100 mg, cyanocobalamin 500
micrograms (mcg), ferrous sulfate 325 mg, furosemide 20 mg, lisinopril 2.5 mg, Lipitor 40 mg, pantoprazole
sodium 40 mg, calcium 600 mg, Eliquis 5 mg, one multivitamin, and Tylenol extended release 650 mg.
Observation and interview on 1/18/19 from 9:05 A.M., with Resident #55 revealed she had received her
anxiety pill at bedtime the night before. Resident #55 confirmed she wrapped it in a tissue and threw it
away. Environmental Service Employee #222 retrieved the plastic waste bag and its contents from Resident
#55's room.
Observation on 12/18/19 at 9:29 A.M., with LPN #120 and Registered Nurse (RN) #104 standing beside
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
the environmental cart the trash bag was emptied and a tissue with a pill inside it was found.
Level of Harm - Minimal harm
or potential for actual harm
Interview with LPN #120 on 12/18/19 at 9:29 A.M., confirmed it was Resident #55's Cymbalta Capsule
Delayed Release that was found in the wrapped in the tissue in her plastic waste bag.
Residents Affected - Few
Review of Resident #55's MAR revealed that on 12/17/19 at 9:00 P.M. Resident #55 was documented as
being administered Cymbalta (antianxiety medication) capsule delayed release particles 30 mg for anxiety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on record review and staff interview, the facility failed to ensure an appropriate diagnosis was
obtained to justify the use of an anti-anxiety medication for one resident. This affected one (#55) of five
residents reviewed for unnecessary medications. The facility census was 82.
Findings include:
Review of Resident # 55's medical record revealed an admission date of 08/04/17 with no cognitive deficits
noted. Diagnoses included atherosclerosis of coronary artery, coronary angioplasty, and chronic kidney
disease. A care plan relative to medical and psychological needs revealed individualized interventions with
measurable goals.
Review of Resident #55's medication administration record revealed on 12/13/19, Resident #55 was
prescribed and given Cymbalta Capsule Delayed Release Particles 30 mg 1 capsule by mouth daily at
bedtime for anxiety.
Review of Resident #55 nurses notes revealed no areas of concern with Resident #55 having anxiety.
Review of the Medication Administration Records (MAR) from 12/01/19 to 12/18/19, revealed Resident #55
started the medication on 12/13/19, for anxiety behavior. Review of the behavior documentation on the
MAR revealed no behaviors indicating the resident was experiencing anxiety.
On 12/17/19 at 4:43 P.M., an interview with Resident #55 revealed she was experiencing back pain and
was upset because the nurse gives her an anxiety pill for the pain.
On 12/18/19 from 9:05 A.M. to 9:29 A.M., observation and interview with Licensed Practical Nurse (LPN)
#120 and Registered Nurse (RN) #104, confirmed Resident #55 was receiving Cymbalta Capsule Delayed
Release Particles 30 mg 1 capsule by mouth daily at bedtime for Anxiety.
On 12/19/19 at 4:00 P.M., interview with the Director of Nursing confirmed there were no indications of
Resident #55 needing an antianxiety medication for pain in Resident #55 medical records or on the MAR to
indicate why she was taking Cymbalta for pain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on record review and staff interview, the facility failed to document the administration of medications
for three residents. This affected three (#2, #132, and #133) of seven residents reviewed for medications.
The census was 82.
Findings include:
1. Review of Resident #2's record revealed an admission date of 08/19/19. Diagnoses included anemia,
hypertension, muscle weakness, and chronic kidney disease.
Review of the medication administration records (MAR's) for December 2019, revealed Resident #2 was
not documented as receiving 9:00 P.M. doses of Trazodone 50 milligrams (mg), Baclofen 20 mg, and
Ferrous Sulfate 325 mg on 12/11/19. Administration boxes for those times were blank and not completed on
the MAR.
2. Review of Resident #132's record revealed an admission date of 12/05/19. Diagnoses included fracture
of left leg, osteoporosis, cardiac pacemaker, and hypothyroidism.
Review of the MAR's for December 2019, revealed Resident #132 was not documented as receiving a 9:00
P.M. dose of Simvastatin 40 mg on 12/11/19 and a 6:00 A.M. dose of Levothyroxine Sodium 100
micrograms (mcg) on 12/12/19. Administration boxes for those times were blank and not completed on the
MAR.
2. Review of Resident #133's record revealed an admission date of 12/06/19. Diagnoses included
respiratory failure, chronic obstructive pulmonary disease, anxiety disorder, and dementia.
Review of the MAR's for December 2019, revealed Resident #133 was not documented as receiving a 9:00
P.M. doses of Pravastatin Sodium 40 mg, Budesonide-Formoterol Fumarate 160-4.5 mcg inhaler, Carvedilol
6.25 mg, Ferrous Sulfate 325 mg, Furosemide 20 mg, Guaifenesin extended release 600 mg, Memantine
Hydrochloride 5 mg, Zanaflex 2 mg on 12/11/19 and a 6:00 A.M. dose of Memantine Hydrochloride 5 mg
on 12/12/19. Administration boxes for those times were blank and not completed on the MAR.
The Director of Nursing (DON) confirmed the missing documentation for Residents #2, #132, and #133
during an interview on 12/19/19 at 8:41 A.M.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/19/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Southbrook Healthcare Center
2299 S Yellow Springs Street
Springfield, OH 45506
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of the facility's Legionnaires prevention documentation and staff interview, the facility failed
to develop and implement an adequate Legionella control plan with identified control measures. This had
the potential to affect 82 of 82 residents who reside in the facility.
Residents Affected - Many
Findings include:
Review of the facility's undated policy titled, Water Management System Control Measure/Monitoring,
revealed water temperatures would be checked weekly for temperatures form 105 Fahrenheit (F) to 120 F.
Water heaters would also be visually inspected every six months to determine if interior cleaning was
required and a water management team would meet quarterly.
Review of facility documentation revealed water temperature checks were completed for hot water
temperatures form 105 F to 120 F. An annual water quality check of city water was completed. However,
there was no documentation of water heater inspections or quarterly water management team meetings
provided.
Interview with Maintenance Worker (MW) #231 on 12/19/19 at 4:10 P.M., revealed room water temperature
checks were completed for temperature ranges from 105 F to 120 F. MW #231 confirmed these ranges
were for resident comfort/safety and not acceptable ranges to control Legionella growth. MW #231 stated
vacant rooms were flushed and shower heads were descaled. MW #231 confirmed there was no
documentation of vacant room flushing or shower head descaling. MW #231 confirmed quarterly water
management meetings were not held.
Interview with the Interim Administrator on 12/19/19 at 4:40 P.M., revealed the facility's water management
control plan for Legionella was not adequate. The Interim Administrator confirmed there was no
documentation of any vacant room flushing, shower head descaling, and that water temperatures checked
were not adequate for eliminating Legionella growth. The Interim Administrator confirmed quarterly water
management meeting were not held.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365424
If continuation sheet
Page 10 of 10
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Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 19, 2019 survey of SOUTHBROOK HEALTHCARE CENTER?
This was a inspection survey of SOUTHBROOK HEALTHCARE CENTER on December 19, 2019. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOUTHBROOK HEALTHCARE CENTER on December 19, 2019?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguish..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.