A list of the most recent deficiencies for Southwood at Norwell Nursing 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-29 | 2023-11-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-11-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-29 | 2023-11-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-29 | 2023-11-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-29 | 2023-11-06 | 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 | 2023-09-29 | 2023-11-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-29 | 2023-11-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-04 | 2022-02-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-05-21 | 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 | 2021-04-16 | 2021-05-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-16 | 2021-05-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-06 | 2019-08-09 | 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 | 2019-03-06 | 2019-08-09 | 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 | 2019-03-06 | 2019-08-09 | 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 | 2019-03-06 | 2019-08-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Develop a communication plan. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-04-04 | 2019-05-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-06 | 2019-04-20 | 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 | 2019-03-06 | 2019-04-20 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-03-06 | 2019-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-06 | 2019-04-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-06 | 2019-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-06 | 2019-04-20 | 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 | 2019-03-06 | 2019-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-06 | 2019-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-06 | 2019-04-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-06 | 2019-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-06 | 2019-04-20 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-03-06 | 2019-04-20 | N |
| Have policies on smoking. | Health | 2019-03-06 | 2019-04-20 | N |
