A list of the most recent deficiencies for Southpointe Rehab 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? |
---|---|---|---|---|
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-11 | 2023-09-26 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-05 | 2023-07-28 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-02 | 2023-06-16 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-02 | 2023-06-16 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-02 | 2023-06-16 | N |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-03-02 | 2023-06-16 | 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 | 2023-03-02 | 2023-06-16 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-02 | 2023-06-02 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-06-02 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-02 | 2023-04-21 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-02 | 2023-04-21 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-02 | 2023-04-21 | N |
Ensure each resident receives an accurate assessment. | Health | 2023-03-02 | 2023-04-21 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-02 | 2023-04-21 | 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 | 2023-03-02 | 2023-04-21 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-04-21 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-04-21 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-02 | 2023-04-21 | 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 | 2023-03-02 | 2023-04-21 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-02 | 2023-04-21 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-02 | 2023-04-21 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-04-21 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-02 | 2023-04-21 | 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 | 2023-03-02 | 2023-04-21 | N |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-02 | 2023-04-21 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Provide emergency officials' contact information. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Use approved construction type or materials. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-20 | 2023-01-23 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-09 | 2021-12-23 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-23 | 2019-12-07 | N |
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-23 | 2019-12-07 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-10-23 | 2019-12-07 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-10-23 | 2019-12-07 | N |
Provide and implement an infection prevention and control program. | Health | 2019-10-23 | 2019-12-07 | N |
Implement a program that monitors antibiotic use. | Health | 2019-10-23 | 2019-12-07 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-23 | 2019-12-07 | N |
Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-12-31 | 2019-01-30 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-12-31 | 2019-01-30 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-12-31 | 2019-01-30 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-31 | 2019-01-30 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-31 | 2019-01-30 | 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 | 2018-12-31 | 2019-01-30 | 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 | 2018-12-31 | 2019-01-30 | N |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-12-31 | 2019-01-30 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-31 | 2019-01-30 | 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 | 2018-12-31 | 2019-01-30 | N |