Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Southbrooke Manor Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when several prepared food items in the refrigerator were missing discard dates, the ice machine had black circular spots inside above the ice, and brooms and mops in the cleaning closet were stored with their heads down touching the floor. During tray prep, a Dietary Aide was also observed with a hair net that had come off and was put back on to cover her entire head/hair. Staff interviews confirmed kitchen staff were responsible for labeling food, overseeing sanitation, and proper storage practices.
Inaccurate medical record documentation was found for two residents. One resident’s chart did not list dementia on the face sheet or physician orders even though hospital paperwork, a BIMS showing severe cognitive impairment, and the care plan referenced dementia. Another resident’s MAR showed Midodrine was given for hypotension, but BP values were not documented at the medication times, despite an order to hold the drug if SBP was over 150 and a policy requiring accurate records.
A resident was admitted without the complete hospital clinical discharge record being available to the admitting physician, leading to a hold on a recommended medication (colchicine) intended for inflammation around the lungs and heart. The physician, lacking full information, withheld the medication until the complete record was received, resulting in the resident missing two doses. Staff interviews confirmed the absence of the full record at admission and acknowledged the impact on continuity of care.
The facility failed to distribute mail to residents on Saturdays, holding it until Monday for sorting by the business office. Residents expressed feeling disrespected by this practice, and the delay could lead to disappointment and sadness. The facility's policy required all incoming mail to be directed to residents, but this was not followed on weekends.
The facility failed to store drugs and biologicals properly, with 17 loose pills found in the 400/600 halls medication cart and 6 loose pills in the 300/500 halls cart. The medication aide and DON acknowledged the risk of residents consuming unintended medications, leading to harmful effects. The Regional RN could not find a specific policy on medication storage, though a facility policy exists to ensure control and surveillance of medications.
A facility failed to maintain the privacy and confidentiality of a resident's medical records when a medication aide left a computer screen unlocked, exposing the resident's medication list. The resident, who had intact cognition and a history of hemiparesis, intracerebral hemorrhage, and gout, was at risk of having their information accessed by unauthorized individuals. The DON emphasized the importance of adhering to HIPAA regulations and the facility's policy on maintaining privacy.
A facility failed to include a resident's anticoagulant medication, Xarelto, in their care plan, despite it being prescribed since April 2022. This omission was confirmed by the DON and a Regional Care Management Support Specialist, who both emphasized the importance of documenting medication use to meet care needs. The facility's policy requires care plans to be reviewed and revised after each MDS assessment, which was not followed.
The facility failed to ensure a CNA completed mandatory QAPI annual training. A review of training records showed that the CNA, re-hired recently, had not fulfilled this requirement. Interviews with the HR Director and Administrator confirmed the absence of a completed training record. The HR Director stated it was the staff's responsibility to complete training, and the Administrator noted that completion would improve resident care. The facility's policy requires all staff to complete necessary training.
The facility failed to secure the medication storage room, which was found propped open and unattended, allowing potential unauthorized access. LVN-A admitted to routinely leaving the door open for convenience, while LVN-B acknowledged it should not have been. The DON confirmed the expectation for the room to remain locked, although no specific policy was in place.
A facility failed to include a resident's fast eating behavior in their care plan, leading to a choking incident. The resident, with a history of dementia and dysphagia, was known to eat quickly and put large amounts of food in his mouth. Despite staff awareness, the care plan lacked interventions for this behavior, resulting in a choking episode that required emergency intervention and hospital transfer. The facility did not have a care plan policy in place at the time.
A resident with severe cognitive impairment and a history of aggressive behavior was transported to a psychiatric hospital without adequate supervision, resulting in the resident attacking the van driver. Despite the resident's documented aggressive behavior, the facility did not provide additional supervision during the transport, relying solely on the van driver. The facility lacked a written policy on accompanying residents during transport, leading to this potentially dangerous situation.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen food preparation area. During observation and interview on 02/17/2026, several prepared food products in the refrigerator did not have discard dates. The CDM and Dietary Aide I stated that night staff were responsible for labeling the food products with discard dates and that kitchen staff were responsible for correcting labels if needed. The CDM also stated it was important to throw out food that was past due for resident safety. The facility’s Food Storage policy did not reflect that prepared foods needed discard dates as required by the 2022 FDA Food Code. The same survey found sanitation and storage issues in the kitchen. An observation of the ice machine showed black circular spots on the inside of the machine directly above the ice, and the CDM stated the machine was old and the spots could not be cleaned off. The Maintenance Director later stated the ice machine was supposed to be cleaned monthly but had not been cleaned that week, and the black dots were wiped with a wet towel. In the kitchen cleaning closet, brooms and mops were observed stored with their heads down touching the floor, while the facility policy required them to be stored head up. During tray preparation on 02/18/2026, Dietary Aide J was observed with a hair net covering her whole head/hair after it had come off and she put it back on; the CDM stated hairnets fell off easily and any kitchen staff member could notice if another staff member was not properly covered.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #43 by not listing dementia on the face sheet or monthly physician orders, even though the resident’s hospital discharge paperwork documented dementia, the BIMS assessment showed severe cognitive impairment, and the care plan included a focus on ADL self-care related to dementia. During interview, the MDS Nurse stated the admission nurses responsible for entering the diagnosis were no longer employed and that the dementia diagnosis had not been entered. The DON stated she had not yet audited all previous admissions for accuracy and acknowledged that listing dementia only in the care plan, rather than on the face sheet, could cause confusion for other providers and may result in the resident not receiving appropriate care. The facility also failed to accurately document Resident #13’s blood pressure in the MAR when Midodrine HCl 10 mg was administered for hypotension. The MAR showed the medication was given on 02/16/2026 at 1:00 PM, 02/17/2026 at 1:00 PM, and 02/17/2026 at 5:00 PM, but no blood pressure was entered for those times. The resident’s orders directed the medication to be held if systolic blood pressure was over 150, and the care plan addressed hypotension related to heart failure. An LVN stated she checked blood pressure and held medications if out of parameters, but could not confirm the specific medication times, and the facility policy required each resident’s medical record to contain an accurate representation.
Failure to Provide Complete Hospital Records at Admission Resulted in Medication Hold
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. Specifically, upon admission from the hospital, the facility did not provide the admitting physician with the resident's complete hospital clinical discharge record. As a result, the physician held a recommended medication, colchicine, which had been prescribed for inflammation around the lungs and heart, not for gout as initially assumed by the physician due to incomplete information. The resident, who had a history of epilepsy, pleural effusion, pericardial effusion, atrial fibrillation, and hypotension, was admitted with only a hospital medication list available to the admitting nurse and physician. The physician, lacking the full clinical context, decided to hold colchicine and another medication, Toradol, until the complete hospital record could be reviewed. This led to the resident missing two doses of colchicine. The medication was reinstated the following day after the physician reviewed the full hospital record and understood the rationale for its use. Interviews with facility staff, including the admitting nurse, DON, business office manager, and administrator, confirmed that the full hospital record was not available at the time of admission, contrary to facility procedures and expectations. The facility's policies did not clearly address the requirement for a complete hospital record at admission, nor did they provide a checklist for reconciling hospital medications and clinical notes. The resident expressed frustration at not receiving the medication as expected, and staff acknowledged the lapse in continuity of care due to the missing documentation.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, particularly on Saturdays. During a confidential group meeting, residents expressed that they did not receive mail on Saturdays and felt disrespected by this practice. Interviews with the Business Manager, DON, and Administrator revealed that mail received on Saturdays was not distributed to residents until the following Monday. The Business Manager and Administrator confirmed that the mail collected on weekends was held until Monday for sorting by the business office before being passed to the Activity Director for distribution. The facility's policy stated that all incoming mail should be directed to the resident, but this was not adhered to on weekends. The DON and Administrator acknowledged that the delay in mail distribution could lead to residents experiencing disappointment and sadness. The Business Manager and Administrator explained that the mail was sorted and distributed by the business office during weekdays, but there was no clear process for weekend mail distribution, leading to the deficiency.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles, as observed in two of the four medication carts. Specifically, the medication aide cart for the 400/600 halls contained 17 loose pills, and the cart for the 300/500 halls contained 6 loose pills. These loose pills were found in the bottom of the cart drawers that held blister packs. During interviews, the medication aide acknowledged that loose pills could fall to the floor and potentially be picked up and consumed by residents for whom they were not prescribed, leading to unwanted and harmful adverse effects. The Director of Nursing (DON) and the Regional Registered Nurse (RN) were interviewed regarding the issue. The DON confirmed that if loose pills were present, residents could inadvertently consume medications not intended for them, resulting in harmful or unwanted effects. The Regional RN was unable to locate a specific facility policy on the storage of medication. However, a review of the facility's policy titled 'Medication Carts and Supplies for Administering Meds,' revised on 10/01/19, indicated that the purpose of the mobile medication system is to ensure appropriate control and surveillance of resident-assigned medications.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, it was noted that a medication aide (MA B) did not lock the computer screen after preparing a resident's morning medication, leaving the resident's medication list exposed. This incident involved a male resident with a history of hemiparesis, intracerebral hemorrhage, and gout, who had intact cognition as indicated by a BIMS score of 15. The medication aide was unaware that minimizing the screen was insufficient for maintaining privacy. The Director of Nursing (DON) was not initially aware of the incident but stated that it was the facility's expectation for nursing staff to adhere to HIPAA regulations by locking computer screens when unattended. The facility's policy on medication administration emphasized maintaining privacy by closing the medication administration record when not in use. The DON highlighted that leaving residents' charts open could lead to unauthorized access, and the Assistant Directors of Nursing (ADONs) were responsible for overseeing compliance with this task.
Failure to Document Anticoagulant Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's use of an anticoagulant medication, Xarelto, which had been prescribed since April 2022. This omission was identified during a review of the resident's ongoing care plan, which had been initiated in March 2018, and was not updated to reflect the resident's current medication regimen. Interviews with the Director of Nurses and the Regional Care Management Support Specialist confirmed that the resident's anticoagulant medication use was not documented in the care plan. Both acknowledged the importance of including this information to ensure that care staff are aware of and can meet the resident's care needs. The facility's policy on comprehensive care plans, dated October 2022, requires that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Ensure Completion of Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA A, completed the mandatory Quality Assurance and Performance Improvement (QAPI) annual training. This deficiency was identified during a review of the annual CNA training records, which revealed that CNA A, who was re-hired on October 10, 2023, had not fulfilled the QAPI training requirement. Interviews with the Human Resources (HR) Director and the Administrator confirmed the absence of a completed training record for CNA A. The HR Director acknowledged her responsibility for coordinating the training program and stated that it was the staff member's responsibility to complete their training assignments. The Administrator also noted that completion of the QAPI training would have enhanced resident care services by ensuring staff met their training requirements. The facility's policy on Training Requirements, dated October 13, 2022, specifies that it is the responsibility of each employee, volunteer, or contract staff to complete required training.
Medication Storage Room Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys. This deficiency was observed in the medication storage room, which was found propped open and unattended. The room was located at the entrance to Hall 300, and at the time of observation, there were no staff inside. LVN-A was seen standing in front of a medication cart on the opposite side of the nurse's station, while LVN-B was positioned at another cart against the wall at the entrance to a different hall. Four residents were present in wheelchairs near the nurse's station, posing a risk of unauthorized access to the medication room. During interviews, LVN-A admitted to routinely propping open the medication room door to facilitate resupplying her cart without repeatedly unlocking and locking the door. She claimed to maintain visual access to the room but acknowledged that in the event of a medical emergency, the room could be left unsupervised. LVN-B confirmed the door was propped open and acknowledged it should not have been. The Director of Nursing (DON) stated that the medication room door should always be closed and locked, and that the facility did not have a specific policy regarding this, although it was expected to remain locked unless accessed by authorized staff.
Failure to Address Resident's Fast Eating Behavior in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with specific eating behaviors that posed a risk to his health. The resident, who had a history of dementia with mood disorder, dysphagia, and other medical conditions, was known to eat quickly and put large amounts of food in his mouth. Despite these behaviors being known to the staff, the care plan did not include interventions to address the resident's fast eating habits, which ultimately led to a choking incident. On the day of the incident, the resident was observed eating dinner when he began to show signs of distress, such as backing away from the table and gesturing for help. The staff responded by performing abdominal thrusts, which successfully dislodged a piece of chicken from the resident's throat. The resident was then transferred to the hospital for further evaluation. Interviews with staff revealed that although the resident's fast eating behavior was known, it was not documented in the care plan, and no speech therapy evaluation had been initiated prior to the choking episode. The Director of Nursing acknowledged that the resident's behavior of eating quickly should have been included in the care plan, as it was out of the regular norm and increased the risk of choking. The facility did not have a care plan policy in place at the time of the incident, which contributed to the oversight in addressing the resident's specific needs. The deficiency highlights the importance of having a comprehensive care plan that includes all known risks and behaviors to ensure the safety and well-being of residents.
Inadequate Supervision During Resident Transport
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1, who had severe cognitive impairment and a history of aggressive behavior, was transported to a psychiatric hospital without adequate supervision. During the transport, Resident #1 attacked the van driver, pulling her hair and choking her while the vehicle was in motion. The van driver managed to park the vehicle and call the police, who calmed Resident #1, allowing the transport to continue without further incident. Resident #1 had a history of aggressive behavior, as documented in multiple progress notes. On several occasions, Resident #1 had been physically aggressive towards other residents and staff, necessitating one-on-one monitoring. Despite this history, the facility did not provide additional supervision during the transport to the psychiatric hospital, relying solely on the van driver, who had previously been able to calm Resident #1. Interviews with the van driver, DON, and Administrator revealed that the facility did not have a written policy regarding accompanying residents during transport. The decision to send additional staff was made on a case-by-case basis. The Administrator confirmed that the policy would change due to this incident, but at the time of the event, the lack of adequate supervision led to a potentially dangerous situation for both Resident #1 and the van driver.
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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 Edna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ganado Nursing And Rehabilitation Center | 11.1 mi | ★★★★★ | 13 | 0 |
| Twin Pines Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 20 | 0 |
| The Courtyard Rehabilitation And Healthcare Center | 20.3 mi | ★★★★★ | 14 | 2 |
| Riverside Oaks | 20.6 mi | ★★★★★ | 19 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 21.4 mi | ★★★★★ | 4 | 0 |
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