Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southbrook Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions, who required two-person assistance for rolling in bed and was identified as a fall risk, was being provided incontinence care by a CNA working alone. The CNA did not verify the resident’s care needs in the Kardex and did not ensure the bed brakes were properly locked. While the resident was being rolled, the bed moved and the resident fell from the bed to the floor, later being diagnosed with a distal clavicle fracture.
Staff failed to thoroughly assess and monitor the skin of a high-risk resident with cognitive impairment, resulting in a new unstageable pressure ulcer that was not identified until it had reached an advanced stage. Despite daily skin sweeps being documented as completed and a care plan outlining preventive measures, the new ulcer was only discovered by a wound nurse practitioner during a later assessment.
Annual evaluations were not completed for several CNAs, as confirmed by personnel file reviews and an interview with the HRM. This lapse had the potential to impact all residents in the facility.
Staff did not store or label food items properly in the kitchen, dry storage, refrigerator, and freezer, leaving multiple containers open, undated, or uncovered, and failing to follow facility policies for food safety and sanitation.
The facility did not obtain properly witnessed written authorization forms before managing the personal funds of two residents, as required by policy. Although representatives signed the consent forms, the witness signature sections were left blank, resulting in incomplete authorization documentation.
A resident with moderate cognitive impairment and multiple medical conditions was found repeatedly covered with a thick blanket and reported her room was too cold. Temperature checks by the Maintenance Director confirmed the room was below the facility's policy range, resulting in discomfort for the resident.
Multiple residents with complex medical and behavioral needs were subjected to repeated verbal abuse by another resident, including being called profane and derogatory names and being yelled at. Staff members, including LPNs and CNAs, witnessed these incidents but did not report them due to fear of retaliation and a belief that no action would be taken. Facility leadership was unaware of the abuse, and no required incident reports or investigations were initiated, despite facility policy mandating prevention and reporting of such abuse.
Staff failed to report multiple incidents of resident-to-resident verbal abuse, where a resident with behavioral issues used profane and offensive language toward three other residents with various medical and cognitive conditions. Despite witnessing or being informed of these events, staff did not file required reports or initiate investigations, citing fear of retaliation and lack of confidence in management response. No self-reported incidents were submitted, and the administrator was unaware of the ongoing abuse.
Staff and residents reported multiple incidents of verbal abuse by one resident toward three others, including the use of profane and offensive language. Despite these reports and direct observations by staff such as LPNs and CNAs, no Self-Reported Incidents were filed and no investigations were conducted, as required by facility policy. Staff cited fear of retaliation and lack of confidence in management as reasons for not reporting the abuse, and the administrator was unaware of the incidents.
Staff did not provide timely incontinence care to a resident dependent on assistance, leaving her without care for an extended period, and failed to provide nail care to another resident who required help with bathing and grooming. Both deficiencies were confirmed by resident and staff interviews, as well as observations, and were not in accordance with facility policies for ADL support.
A resident with right-sided hemiplegia and limited ROM did not have the prescribed rolled cloth or cloth carrot in her right hand as required by her care plan. Staff interviews confirmed the device was missing and had not been replaced, despite therapy recommendations.
A resident with severe cognitive impairment and high fall risk, who required assistance from two or more staff for bed mobility, was left unsupervised by a CNA performing peri-care alone. This resulted in the resident rolling out of bed and sustaining injuries, contrary to the care plan and facility policy.
Staff did not adhere to proper hand hygiene protocols during medication administration and food handling. An LPN handled medication with bare hands before placing it in a medication cup for a resident, and a CNA assembled a sandwich for another resident using ungloved hands to touch bread and condiments. Both staff members confirmed their actions were not in line with facility policy.
An LPN failed to prime insulin pens before administering insulin to a resident with type two diabetes, leading to a significant medication error. The resident required insulin as per a sliding scale and scheduled doses, but the LPN administered Insulin Aspart and Insulin Glargine without priming, contrary to manufacturer instructions and facility guidelines.
A facility failed to maintain an infection prevention and control program when a resident on enhanced barrier precautions did not receive proper care. An LPN and a CNA did not wear gowns during care, and the LPN did not change gloves or perform hand hygiene between tasks. This was against the facility's policies, which require hand hygiene and gown use during high-contact activities.
A facility failed to follow infection control precautions during wound care for a resident. An RN did not sanitize bandage scissors after removing a gauze dressing and used them to cut a new dressing. The RN also failed to wash or sanitize hands between glove changes. The resident had multiple diagnoses, including heart disease and kidney disease, and was cognitively intact.
A resident reported an allegation of abuse involving an LPN, but the facility did not report the incident to the State Survey Agency, believing it did not occur. The facility's policy required reporting all allegations, but this was not followed.
Failure to Follow Care Plan and Secure Bed During Incontinence Care Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring during incontinence care, resulting in a resident rolling out of bed and sustaining a fracture. The resident had diagnoses including end stage renal disease, cerebral infarction, and type 2 diabetes, and an MDS assessment showed moderate cognitive impairment with dependence on staff for ADLs. The resident’s care plan specified the need for one staff member to assist with personal hygiene and toileting, and two staff members for rolling side to side in bed. The care plan also identified the resident as being at risk for falls, with interventions including ensuring the bed wheels were locked. On the date of the incident, a CNA provided incontinence care to the resident alone and rolled the resident in bed without obtaining the required second staff member. During this care, the bed moved because the brakes were not effectively locked, and the resident rolled out of bed onto the floor, initially with no visible injuries or complaints of pain. A subsequent physician progress note documented that the resident later complained of left shoulder pain, and an X-ray confirmed a distal left clavicle fracture. The facility’s self-reported incident investigation determined that the resident fell out of bed while the CNA was providing incontinence care alone, that the resident required two-person assistance for rolling in bed, and that the CNA failed to use the Kardex to verify care needs and did not ensure the bed brakes were properly locked.
Failure to Timely Identify and Assess Pressure Ulcers
Penalty
Summary
Facility staff failed to thoroughly assess and monitor the skin condition of a resident who was admitted with multiple pressure ulcers and identified as high risk for developing additional ulcers. Despite physician orders for daily skin sweeps and a care plan that included interventions such as regular repositioning, off-loading devices, and daily wound evaluation, documentation indicated that staff signed off on completing daily skin sweeps without detecting new skin issues. Weekly skin assessments initially reported no new concerns, but a subsequent assessment revealed new skin issues. Ultimately, a wound nurse practitioner identified an unstageable pressure ulcer with slough and necrotic tissue on the resident's right gluteal fold, which had not been previously documented by staff. The resident involved had significant cognitive impairment and required extensive assistance with activities of daily living. The facility's own policy and national guidelines require comprehensive and ongoing skin assessments, particularly for high-risk individuals. However, the new pressure ulcer was not identified until it had progressed to an advanced stage, indicating a failure in timely detection and intervention by staff. The Director of Nursing confirmed that the pressure ulcer was not recognized until it had become unstageable, despite daily documentation indicating that skin sweeps were performed.
Failure to Complete Annual Staff Evaluations
Penalty
Summary
The facility failed to complete annual evaluations for its staff, specifically for three Certified Nursing Assistants (CNAs) whose personnel files were reviewed. The personnel records showed that each of these CNAs had been employed for over a year or close to a year, yet there was no documentation of annual evaluations in their files. During an interview, the Human Resource Manager confirmed that annual evaluations had not been completed for these staff members. This deficiency had the potential to affect all 90 residents residing in the facility, as regular staff evaluations are necessary to ensure quality care.
Failure to Store and Label Food Items Properly in Kitchen and Storage Areas
Penalty
Summary
Staff failed to store food in a safe and sanitary manner, as observed during a kitchen inspection with the Dietary Manager. In the dry storage area, there were eleven undated cereal bowls, an open container of breadcrumbs, four clear plastic containers of cereal with cloudy sides and residue buildup, and similar issues with containers of sugar, flour, and brown sugar. Additionally, an unrefrigerated sheet cake and an uncovered trash can filled with waste were present. In the walk-in refrigerator, there were undated packages of salami, individually wrapped dinner rolls, premade salads, bowls of coleslaw, and an uncovered package of butter. The walk-in freezer contained two pitchers of ice and boxes of beef and sausage patties, all open to air. The Dietary Manager confirmed these concerns. Facility policies required all foods to be properly sealed, labeled, dated, and stored in a manner to prevent cross-contamination, which was not followed in these instances.
Failure to Obtain Proper Written Authorization for Management of Resident Funds
Penalty
Summary
The facility failed to obtain appropriate written authorization to manage the personal funds of two residents. For both residents, the authorization forms allowing the facility to manage their funds were signed by their representatives, but the required witness signatures were missing. The forms included designated spaces for two witnesses, but these were left blank. This was confirmed during an interview with the Administrator, who acknowledged that the proper written authorization had not been obtained for these residents. The residents involved had significant medical histories, including diagnoses such as cerebral infarction, hypotension, anxiety disorder, cerebral vascular accident, transient ischemic attack, and dementia. Despite the facility's policy requiring written designation when accepting responsibility for a resident's financial affairs, the lack of witnessed signatures on the authorization forms constituted a failure to follow this policy.
Failure to Maintain Resident Room Temperature Within Policy Range
Penalty
Summary
The facility failed to maintain a comfortable room temperature for a resident with diagnoses including epilepsy, depression, and cerebral infarction. The resident, who was moderately cognitively impaired and required staff assistance with activities of daily living, was observed on multiple occasions to be in bed covered with a thick blanket. During interviews, the resident consistently reported that her room was too cold. Temperature measurements taken in the resident's room by the Maintenance Director confirmed that the room temperature was below the facility's policy range of 71 to 81 degrees Fahrenheit, with readings of 68 and 70.2 degrees Fahrenheit on separate occasions. The facility's policy on extreme cold temperature protocol specifies that ambient air temperature should be maintained within this range to ensure a safe and comfortable environment. The failure to maintain the required temperature range resulted in the resident experiencing discomfort due to cold room conditions.
Failure to Prevent and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, specifically resident-to-resident abuse, as evidenced by multiple incidents involving one resident verbally abusing others. Three residents with varying medical conditions, including schizophrenia, congestive heart failure, diabetes, cerebral infarction, major depressive disorder, hypertension, COPD, and alcohol-induced psychotic disorder, were subjected to repeated verbal abuse by another resident. These incidents included being called profane and derogatory names, being yelled at, and being chased in a wheelchair. The affected residents were cognitively intact or had moderate cognitive impairment and required varying levels of assistance with activities of daily living. Staff members, including LPNs and CNAs, directly witnessed the abusive behavior but did not report the incidents to facility leadership. Staff interviews revealed a fear of retaliation and a belief that reporting the abuse would not result in any action, as the abusive resident was perceived to have caused staff suspensions or terminations in the past. The Director of Plant Maintenance also observed the abuse but did not report it. Residents confirmed the ongoing verbal abuse and expressed feelings of offense and embarrassment, with one resident stating that nothing was done after reporting the abuse to staff. The facility's records showed no Self-Reported Incidents (SRIs) or investigations related to these allegations during the relevant period. The facility's policy required prevention of all forms of abuse, including resident-to-resident verbal abuse, but this policy was not followed. The Administrator confirmed a lack of awareness of the recent allegations and acknowledged that no SRIs or investigations had been initiated regarding the reported incidents.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident verbal abuse to the Ohio Department of Health as required. Multiple staff members, including LPNs and a CNA, directly witnessed or were informed of incidents where one resident verbally abused other residents by using profane and offensive language. Despite these observations, staff did not report the incidents due to fear of retaliation or belief that management would not take action. The administrator confirmed a lack of awareness regarding these recent allegations and acknowledged that no self-reported incidents (SRIs) had been filed or investigations conducted for these events. Three residents with varying medical and cognitive conditions were affected by the unreported verbal abuse. One resident with schizophrenia, CHF, and diabetes was called profane names and reported feeling offended due to his religious beliefs. Another resident with cerebral infarction and major depressive disorder was subjected to cursing and derogatory remarks, while a third resident with COPD and alcohol-induced psychotic disorder experienced repeated verbal abuse and reported it to staff without any follow-up action. The resident responsible for the abuse had a documented history of behavioral problems, including yelling, inappropriate language, and aggression toward both staff and residents. Review of facility records, including care plans and physician orders, confirmed that interventions were in place to address behavioral issues, but these were not effectively implemented or followed up with required reporting. The facility's own policy mandates reporting allegations of abuse to the state agency, yet no SRIs were filed for the incidents in question, and no investigations were initiated. Staff interviews further corroborated that the abuse was ongoing and unaddressed, with multiple staff members admitting to witnessing or being aware of the incidents but failing to report them.
Failure to Investigate Allegations of Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate multiple allegations of verbal abuse by one resident towards three other residents. Medical record reviews and interviews revealed that the residents involved had various diagnoses, including schizophrenia, congestive heart failure, diabetes, cerebral infarction, major depressive disorder, hypertension, COPD, and alcohol-induced psychotic disorder. Despite being cognitively intact or only moderately impaired, the affected residents reported being subjected to repeated verbal abuse, including profane and offensive language, by another resident. Staff members, including LPNs and CNAs, witnessed these incidents but did not report them due to fear of retaliation or belief that management would not act. Further review showed that the facility had not filed any Self-Reported Incidents (SRIs) or conducted investigations related to these allegations during the relevant period. The facility's own policy requires investigation of all abuse allegations, but interviews with staff and the administrator confirmed that no such investigations had taken place. The administrator was unaware of the recent allegations, and the facility's records did not reflect any action taken in response to the reported verbal abuse.
Failure to Provide Timely Incontinence and Nail Care for Dependent Residents
Penalty
Summary
Staff failed to provide timely incontinence care and nail care for two residents who required assistance with activities of daily living (ADLs). One resident with multiple sclerosis and glaucoma, who was always incontinent and dependent on staff for incontinence care, did not receive toileting or incontinence care on a specific day. The resident reported asking to be changed multiple times but was left in her wheelchair for 16 hours without care. Staff interviews confirmed that incontinence care was not provided due to short staffing and a facility event occurring that day. Facility policy required staff to provide incontinence care to dependent residents to maintain hygiene standards. Another resident with hypothyroidism, epilepsy, and post-traumatic stress disorder, who required moderate staff assistance with bathing and grooming, was observed to have long, dirty fingernails and toenails throughout the day. The resident confirmed that aides did not trim or clean her nails, and a CNA acknowledged that nail care should have been provided on bath day. Facility policy indicated that routine daily care should include assistance with bathing and grooming, including nail care.
Failure to Provide Prescribed Range of Motion Device
Penalty
Summary
A resident with a history of epilepsy, depression, and cerebral infarction resulting in right-sided hemiplegia and hemiparesis was identified as having an activities of daily living (ADL) self-care deficit. The resident's care plan included an intervention to place a rolled cloth in her right hand as tolerated to address limited range of motion (ROM). Medical record review and observations on multiple occasions revealed that the resident did not have the prescribed rolled cloth or any similar device in her right hand. During interviews, the resident confirmed that staff previously placed a carrot-shaped device in her right hand, but it had been discarded and not replaced. A registered nurse acknowledged that the resident should have had a rolled cloth in her hand but did not. The therapy manager confirmed that therapy had recommended the use of a cloth carrot in the resident's right hand and was unaware that it had been lost. These findings demonstrate that the facility failed to ensure the prescribed ROM device was in place for the resident.
Failure to Provide Required Supervision During Transfer Results in Resident Fall
Penalty
Summary
Staff failed to provide the required level of supervision during a transfer, resulting in a fall with injury for a resident. The resident, who had diagnoses including cerebral infarction, vascular dementia, and anxiety disorder, was assessed as having severe cognitive impairment and was dependent on staff for all activities of daily living, including bed mobility. The care plan specified that two or more staff were needed to assist with bed mobility and peri-care due to the resident's deficits and high fall risk. Despite these documented needs, a CNA performed peri-care alone and rolled the resident onto his side, which led to the resident rolling out of bed and falling to the floor. The resident sustained a skin tear to the right elbow and bruising to the forehead, requiring hospital evaluation before returning to the facility. The facility's policy required care plans to address ADL needs and provide appropriate physical care, but this was not followed in this instance.
Failure to Follow Hand Hygiene During Medication Administration and Food Handling
Penalty
Summary
Staff failed to follow safe hand hygiene practices during medication administration and food handling, as observed in two separate incidents. In the first instance, an LPN prepared medications for a resident by removing medication from a dose pack and placing it in her ungloved hand before transferring it to a medication cup, contrary to facility policy that prohibits touching medications with ungloved hands. In the second instance, a CNA served a resident a turkey club sandwich and, without wearing gloves, handled the bread, mayonnaise, lettuce, tomato, and onion while assembling the sandwich for the resident. Both staff members confirmed during interviews that they had handled medications and food with ungloved hands and acknowledged this was not in accordance with facility policy.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. During an observation, it was noted that an LPN did not prime insulin pens before administering insulin to a resident. The resident, who had a history of multiple sclerosis, asthma, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, anemia, convulsions, and chronic ischemic heart disease, required insulin administration as per a sliding scale and scheduled doses. However, the LPN administered 24 units of Insulin Aspart and 10 units of Insulin Glargine without priming the pens, which is a necessary step to ensure accurate dosing. The manufacturer's instructions for both Insulin Aspart and Insulin Glargine require that the pens be primed with two units before each injection to avoid injecting air and to ensure proper dosing. The facility's insulin reference guide also specifies this priming requirement. The LPN confirmed during an interview that she did not prime the insulin pens prior to administration. This oversight was identified as a deficiency during a complaint investigation, indicating non-compliance with the requirement to keep residents free from significant medication errors.
Infection Control Deficiency Due to Improper Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions during wound care for a resident. The resident, who was severely cognitively impaired, had multiple diagnoses including Alzheimer's disease, dementia, and hypertension, and required specific wound care orders for a left heel and sacrum wound. Despite the resident being on enhanced barrier precautions, staff did not adhere to the necessary protocols. During an observation, a CNA and an LPN provided incontinence and wound care to the resident without wearing gowns, as required by the enhanced barrier precautions. The LPN was observed not changing gloves after removing soiled dressings and failed to perform hand hygiene between glove changes. This was in direct violation of the facility's policies on enhanced barrier precautions and personal protective equipment, which mandate hand hygiene before and after glove use and the use of gowns during high-contact care activities.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control precautions during wound care for a resident. The incident involved a registered nurse (RN) who did not sanitize bandage scissors after using them to remove a gauze dressing from the resident's left leg. The RN then used the same unsanitized scissors to cut a Xeroform dressing before applying it to the wound. Additionally, the RN did not wash or sanitize her hands between glove changes or after removing the old wound dressing and applying the new one. The resident involved was cognitively intact and had multiple diagnoses, including atherosclerotic heart disease, chronic kidney disease, peripheral vascular disease, osteoarthritis, depression, scoliosis, and dysphagia. The facility's policy on standard precautions required staff to change gloves after contact with non-intact skin or wound dressings and to sanitize hands after glove removal. The RN confirmed during an interview that she did not follow these procedures, leading to the deficiency noted in the report.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency in a timely manner, affecting one resident. Resident #79, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and acute and chronic respiratory failure, reported an allegation of abuse on 04/11/24 to the Administrator. The allegation involved an LPN sticking her finger in the resident's face. Despite the resident's report, the facility chose not to report the incident to the State Survey Agency, believing the incident did not occur. Witness statements were collected, and the incident was investigated internally. The facility's self-reported incidents for 2024 showed no reports submitted regarding the allegation made by Resident #79. The Administrator confirmed that the facility's policy required any allegation or suspicion of abuse to be investigated and reported to the State Survey Agency. However, this policy was not followed in this case. The facility's abuse policy emphasized providing resident-centered care and taking measures to protect residents from harm during investigations, including accurate and timely reporting of incidents in accordance with state law.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Masonic Community | 2.3 mi | ★★★★★ | 16 | 0 |
| Wooded Glen | 3.3 mi | ★★★★★ | 1 | 0 |
| Springfield Nursing & Independent Living | 3.3 mi | ★★★★★ | 4 | 0 |
| Arbors At Springfield | 3.6 mi | ★★★★★ | 3 | 0 |
| Good Shepherd Village | 4 mi | ★★★★★ | 0 | 0 |
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