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Deficiency Records for Southwood at Norwell Nursing Ctr

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.

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

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