A list of the most recent deficiencies for Southside 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-30 | 2024-02-09 | 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 | 2023-11-30 | 2024-02-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-02-09 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-30 | 2024-02-09 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-30 | 2024-02-09 | 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 | 2023-11-30 | 2024-02-09 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-30 | 2024-02-09 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-30 | 2024-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-02-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-30 | 2024-02-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-30 | 2024-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-02-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-30 | 2024-02-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-30 | 2024-02-09 | N |
| Use approved construction type or materials. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-11-29 | 2024-02-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-19 | 2023-01-06 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-19 | 2023-01-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-19 | 2023-01-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-19 | 2023-01-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-19 | 2023-01-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-19 | 2023-01-06 | 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 | 2022-10-19 | 2023-01-06 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-19 | 2023-01-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-19 | 2023-01-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-19 | 2023-01-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-19 | 2023-01-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-19 | 2023-01-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-19 | 2023-01-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Develop a communication plan. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish methods for sharing information. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-19 | 2022-12-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-04 | 2020-01-18 | 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 | 2019-12-04 | 2020-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-04 | 2020-01-18 | N |
| Request a waiver if it can't meet the nurse staffing requirements. | Health | 2019-12-04 | 2020-01-18 | 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 | 2019-12-04 | 2020-01-18 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-12-04 | 2020-01-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-04 | 2020-01-18 | N |
