A list of the most recent deficiencies for Southridge Rehab and Living Ctr. 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? |
|---|---|---|---|---|
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-06 | 2023-04-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-06 | 2023-04-24 | 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 | 2023-03-10 | 2023-04-12 | 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 | 2023-03-10 | 2023-04-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-10 | 2023-04-12 | 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 | 2023-03-10 | 2023-04-12 | 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 | 2023-03-10 | 2023-04-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-10 | 2023-04-12 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-10 | 2023-04-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-03-10 | 2023-04-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-10 | 2023-04-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-04-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-03-10 | 2023-04-12 | N |
| Report COVID19 data to residents and families. | Health | 2023-03-10 | 2023-04-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-05 | 2023-01-13 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2022-12-05 | 2023-01-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-25 | 2021-12-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-25 | 2021-12-09 | 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 | 2021-04-15 | 2021-07-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-15 | 2021-07-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-15 | 2021-06-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-15 | 2021-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-15 | 2021-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-23 | 2019-07-11 | 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 | 2023-05-31 | Not Fixed | Y |
