A list of the most recent deficiencies for Southpoint Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-01 | 2023-12-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-01 | 2023-12-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-01 | 2023-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-01 | 2023-12-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2023-12-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-01 | 2023-12-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-10-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-08-10 | 2023-08-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-08-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-07-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-07-17 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-06-09 | 2023-07-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-09 | 2023-07-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-09 | 2023-07-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-09 | 2023-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-09 | 2023-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-09 | 2023-07-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-09 | 2023-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-09 | 2023-07-17 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-09 | 2023-06-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-09 | 2023-06-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-06-26 | N |
| 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. | Health | 2023-06-09 | 2023-06-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-09 | 2023-06-26 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-09 | 2023-06-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-18 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-18 | 2023-05-22 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-13 | 2023-04-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-13 | 2023-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-13 | 2023-04-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-24 | 2023-03-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-24 | 2023-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-24 | 2023-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-03-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-24 | 2023-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-24 | 2023-03-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-24 | 2023-03-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-24 | 2023-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-02 | 2022-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-02 | 2022-12-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-12-02 | 2022-12-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-02 | 2022-12-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-24 | 2022-11-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-24 | 2022-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-24 | 2022-11-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-24 | 2022-11-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-20 | 2022-11-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-03 | 2022-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-03 | 2022-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-03 | 2022-10-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-03 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-03 | 2022-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-03 | 2022-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-03 | 2022-10-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-03 | 2022-10-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-03 | 2022-10-18 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-26 | 2022-09-09 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-11 | 2022-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-14 | 2022-06-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-14 | 2022-06-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-14 | 2022-06-24 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-31 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-18 | 2022-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-18 | 2022-06-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-18 | 2022-06-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-18 | 2022-06-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-18 | 2022-06-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-18 | 2022-06-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-18 | 2022-06-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-18 | 2022-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-18 | 2022-06-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-18 | 2022-06-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-18 | 2022-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-18 | 2022-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-18 | 2022-06-11 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-05-18 | 2022-06-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-18 | 2022-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-28 | 2022-05-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-28 | 2022-05-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-17 | 2022-03-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-17 | 2022-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-17 | 2022-03-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-17 | 2022-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-17 | 2022-03-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-20 | 2022-02-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-20 | 2022-02-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-06 | 2022-01-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-01-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-01-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-06 | 2022-01-21 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-01-06 | 2022-01-21 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-01-06 | 2022-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-01-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-21 | 2021-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-21 | 2021-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-29 | 2021-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-27 | 2021-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-27 | 2021-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-27 | 2021-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-01 | 2021-07-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-02 | 2021-05-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-29 | 2021-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-29 | 2021-05-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-04 | 2021-04-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-19 | 2021-03-26 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-04 | 2021-03-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-19 | 2021-03-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-02-19 | 2021-03-02 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-02-19 | 2021-03-02 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-02-19 | 2021-03-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-19 | 2021-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-19 | 2021-03-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-02-19 | 2021-03-02 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-02-19 | 2021-03-02 | N |
