Deficiency Records for Southbridge Rehabilitation and Health Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Southbridge Rehabilitation and 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-11-09 | 2023-12-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-09 | 2023-12-17 | 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 | 2023-11-09 | 2023-12-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-09 | 2023-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-09 | 2023-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-09 | 2023-12-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-25 | 2023-12-03 | N |
| 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 | 2023-10-25 | 2023-12-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-25 | 2023-12-03 | 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 | 2023-10-25 | 2023-12-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-25 | 2023-12-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-10-25 | 2023-12-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-25 | 2023-12-03 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-10-25 | 2023-12-03 | 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 | 2023-10-25 | 2023-12-03 | 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 | 2023-10-25 | 2023-12-03 | 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 | 2023-10-25 | 2023-12-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-25 | 2023-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-23 | 2022-11-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-23 | 2022-11-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-23 | 2022-11-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-09-23 | 2022-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-23 | 2022-11-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-23 | 2022-11-07 | N |
| Provide appropriate foot care. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-23 | 2022-11-07 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2022-09-23 | 2022-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-23 | 2022-11-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-23 | 2022-11-07 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-23 | 2022-11-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-27 | 2022-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-27 | 2022-10-28 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-27 | 2022-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-27 | 2022-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-01 | 2021-07-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-01 | 2021-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-01 | 2021-07-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-01 | 2021-07-28 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-01 | 2021-07-28 | 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 | 2021-06-01 | 2021-07-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide or obtain dental services for each resident. | Health | 2021-06-01 | 2021-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-01 | 2021-07-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-01 | 2021-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-01 | 2021-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-07 | 2021-07-19 | N |
