A list of the most recent deficiencies for Southeast Health Care 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-30 | 2023-12-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-30 | 2023-12-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-19 | 2023-10-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-07 | 2023-03-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-07 | 2023-03-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-10-12 | 2022-11-21 | N |
| Keep all essential equipment working safely. | Health | 2022-10-12 | 2022-11-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-12 | 2022-11-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-10-12 | 2022-11-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-12 | 2022-11-01 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-12 | 2022-11-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-12 | 2022-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-12 | 2022-11-01 | 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 | 2022-10-12 | 2022-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-12 | 2022-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-12 | 2022-11-01 | N |
| 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 | 2022-10-12 | 2022-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-12 | 2022-11-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-12 | 2022-11-01 | N |
| Post nurse staffing information every day. | Health | 2022-10-12 | 2022-11-01 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-10-12 | 2022-11-01 | 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 | 2022-10-12 | 2022-11-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-10-12 | 2022-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-12 | 2022-11-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-12 | 2022-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-12 | 2022-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-12 | 2022-10-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-12 | 2022-10-24 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-12 | 2022-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-25 | 2021-06-25 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-10-13 | 2020-12-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-13 | 2020-12-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-15 | 2020-12-13 | N |
| Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source | Health | 2020-10-13 | 2020-12-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-13 | 2020-12-02 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-10-13 | 2020-12-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-13 | 2020-12-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-10-13 | 2020-12-02 | 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 | 2020-10-13 | 2020-12-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-10-13 | 2020-12-02 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2020-10-13 | 2020-12-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-10-13 | 2020-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-13 | 2020-12-02 | N |
| Perform COVID19 testing on residents and staff. | Health | 2020-10-13 | 2020-12-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-05 | 2019-05-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-20 | 2019-04-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-03-20 | 2019-04-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-05 | 2019-04-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-05 | 2019-04-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-05 | 2019-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-05 | 2019-04-19 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-03-05 | 2019-04-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-05 | 2019-04-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-03-05 | 2019-04-19 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-03-05 | 2019-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-20 | 2019-04-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-20 | 2019-04-16 | N |
