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Deficiency Records for Southbrook Healthcare Center
View the most recent health deficiencies and inspection results for Southbrook Healthcare Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Southbrook Healthcare Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-05-27 | 2025-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-27 | 2025-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-27 | 2025-06-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-05-27 | 2025-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-27 | 2025-06-18 | 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 | 2025-05-27 | 2025-06-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-05-27 | 2025-06-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-05-27 | 2025-06-18 | N |
| Respond appropriately to all alleged violations. | Health | 2025-05-27 | 2025-06-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-27 | 2025-06-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-05-27 | 2025-06-18 | 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 | 2025-05-27 | 2025-06-18 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2025-05-27 | 2025-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-05-27 | 2025-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-05-27 | 2025-06-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-05-27 | 2025-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-05-27 | 2025-06-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-05-27 | 2025-06-18 | 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 | 2025-05-27 | 2025-06-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-02-18 | 2025-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-02-18 | 2025-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-19 | 2024-10-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-09 | 2024-05-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-25 | 2023-11-03 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-17 | 2023-01-25 | N |
| 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 |
| 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 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 | 2022-11-17 | 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 | 2022-11-17 | 2023-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-17 | 2023-01-25 | N |
| Provide and implement an infection prevention and control program. | 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 |
| 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 |
| 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-19 | 2020-01-23 | N |
| 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 that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-19 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-17 | Not Fixed | Y |