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Deficiency Records for South Mountain Rehab Center
View the most recent health deficiencies and inspection results for South Mountain Rehab Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for South Mountain Rehab Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-12-20 | 2025-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-12-20 | 2025-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-12-20 | 2025-02-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-12-20 | 2025-01-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-20 | 2025-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-12-20 | 2025-01-31 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-12-20 | 2025-01-31 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-20 | 2025-01-31 | 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 | 2024-12-20 | 2025-01-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-12-20 | 2025-01-31 | 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 | 2024-12-20 | 2025-01-31 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-12-20 | 2025-01-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-12-20 | 2025-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-12-20 | 2025-01-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-12-20 | 2025-01-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-12-20 | 2025-01-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-12-20 | 2025-01-31 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-12-20 | 2025-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-20 | 2025-01-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-12-20 | 2025-01-31 | N |
| Provide activities to meet all resident's needs. | Health | 2024-12-20 | 2025-01-31 | 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 | 2024-12-20 | 2025-01-31 | 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 | 2024-12-20 | 2025-01-31 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-12-20 | 2025-01-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-12-20 | 2025-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-12-20 | 2025-01-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-12-20 | 2025-01-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-12-20 | 2025-01-31 | 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 | 2019-11-01 | 2019-12-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-01 | 2019-12-17 | 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 | 2019-11-01 | 2019-12-17 | 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 | 2019-11-01 | 2019-12-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-01 | 2019-11-18 | 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 | 2019-11-01 | 2019-11-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-01 | 2019-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-01 | 2019-11-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-01 | 2019-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-01 | 2019-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-11-01 | 2019-11-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-11 | 2018-06-25 | 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 | 2018-05-11 | 2018-06-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-11 | 2018-06-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-11 | 2018-06-25 | 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 | 2018-05-11 | 2018-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-11 | 2018-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-11 | 2018-06-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-05-11 | 2018-06-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-11 | 2018-06-25 | 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 | 2018-05-11 | 2018-06-25 | 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 | 2018-05-11 | 2018-06-25 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-05-11 | 2018-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-11 | 2018-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-11 | 2018-06-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-05-11 | 2018-06-15 | 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 | 2018-05-11 | 2018-06-15 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-11 | 2018-06-15 | N |