A list of the most recent deficiencies for Southbrook Healthcare 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-10-25 | 2023-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-05-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-17 | 2023-01-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-17 | 2023-01-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-17 | 2023-01-25 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-11-17 | 2023-01-25 | 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 | 2022-11-17 | 2023-01-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2023-01-25 | 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 | 2022-11-17 | 2023-01-25 | 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 | 2022-11-17 | 2023-01-25 | 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 | 2022-11-17 | 2023-01-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-11-17 | 2023-01-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-15 | 2023-01-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-09-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-14 | 2021-04-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-14 | 2021-04-30 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-19 | 2020-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-19 | 2020-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-19 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-23 | 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 | 2019-12-23 | 2020-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-23 | 2020-01-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-11-30 | 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 | 2018-10-25 | 2018-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-25 | 2018-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-25 | 2018-11-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-25 | 2018-11-30 | 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 | 2018-10-25 | 2018-11-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-10-24 | 2018-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-10-24 | 2018-11-30 | 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 | 2018-10-24 | 2018-11-30 | N |
