Deficiency Records for Southern Hills Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Southern Hills Rehabilitation 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-01 | 2023-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-01 | 2023-12-20 | 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 | 2023-11-01 | 2023-12-20 | 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 | 2023-11-01 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-01 | 2023-12-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-01 | 2023-12-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-25 | 2023-06-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-28 | 2023-04-17 | Y |
| 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 | 2021-12-16 | 2022-03-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-16 | 2022-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-16 | 2022-02-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-12-16 | 2022-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-16 | 2022-02-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-16 | 2022-02-28 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-16 | 2022-02-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-16 | 2022-02-28 | Y |
| 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 | 2021-12-14 | 2022-02-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-14 | 2022-02-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-14 | 2022-02-28 | 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 | 2021-12-14 | 2022-02-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-12-14 | 2022-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-14 | 2022-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-16 | 2022-01-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-30 | 2021-12-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-18 | 2021-11-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-18 | 2021-11-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-18 | 2021-11-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-18 | 2021-11-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-18 | 2021-11-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-18 | 2021-11-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-05 | 2020-02-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-05 | 2020-01-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-12-05 | 2020-01-10 | 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 | 2019-12-05 | 2020-01-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-05 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-05 | 2020-01-10 | 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 | 2019-12-05 | 2020-01-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-12-05 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-04 | 2019-12-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-04 | 2019-12-30 | 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 | 2019-02-28 | 2019-03-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-28 | 2019-03-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-02-28 | 2019-03-30 | N |
