Deficiency Records for Southfield Village
Updated as of June 01, 2022
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-21 | 2021-12-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-06 | 2021-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-15 | 2021-01-14 | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-10-28 | 2020-10-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-08 | 2019-06-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-08 | 2019-06-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-08 | 2019-06-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-08 | 2019-06-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-01 | 2019-05-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-01 | 2019-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-01 | 2019-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-01 | 2019-05-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-01 | 2019-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-01 | 2019-05-01 | N |
| 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 necessary and PRN use is limited. | 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 |
