A list of the most recent deficiencies for Southern Hills Health and Reha. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-31 | 2023-11-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-08-25 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-10 | 2023-08-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-24 | 2022-09-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-25 | 2022-06-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-06-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-25 | 2022-06-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-25 | 2022-06-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-25 | 2022-06-13 | 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 | 2022-05-25 | 2022-06-13 | 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 | 2022-05-23 | 2022-06-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-23 | 2022-06-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-23 | 2022-06-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-23 | 2022-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-23 | 2022-06-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-22 | 2022-04-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-22 | 2022-04-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-02 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-24 | Y |
| 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 | 2019-04-12 | 2019-05-28 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-04-12 | 2019-05-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-12 | 2019-05-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2019-04-10 | 2019-05-28 | 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 | 2019-04-10 | 2019-05-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-10 | 2019-05-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-22 | 2018-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-03-22 | 2018-04-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-22 | 2018-04-20 | N |
| Post nurse staffing information every day. | Health | 2018-03-22 | 2018-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-22 | 2018-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-22 | 2018-04-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-22 | 2018-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-22 | 2018-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-20 | 2018-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-20 | 2018-04-20 | N |
