Deficiency Records for Southfield Village
Updated as of September 01, 2018
This is not the most recent data for Southfield Village. For the most recent information, click here.
A list of the most recent deficiencies for Southfield Village. 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? |
|---|---|---|---|---|
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-22 | 2018-04-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-02-08 | 2018-03-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-02-08 | 2018-03-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-08 | 2018-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-08 | 2018-03-10 | 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 ne | Health | 2018-02-08 | 2018-03-10 | 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 | 2018-02-08 | 2018-03-10 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2017-04-17 | 2017-05-10 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2017-04-17 | 2017-05-08 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2017-04-17 | 2017-05-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-21 | 2017-04-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-21 | 2017-04-14 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-21 | 2017-04-14 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-21 | 2017-04-14 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-02-21 | 2017-03-02 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-02-21 | 2017-03-02 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-02-21 | 2017-03-02 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-02-21 | 2017-03-02 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Horizontal exits. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-02-09 | 2016-03-10 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-01-19 | 2016-02-18 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-09-11 | 2015-10-11 | Y |
