Deficiency Records for Southern Hills Rehabilitation Center
Updated as of January 01, 2020
This is not the most recent data for Southern Hills Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-30 | 2019-06-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-30 | 2019-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-24 | 2019-05-10 | Y |
| 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-05 | 2019-03-30 | Y |
| 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 | 2019-03-05 | 2019-03-30 | 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 | 2019-03-05 | 2019-03-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-05 | 2019-03-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-05 | 2019-03-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-05 | 2019-03-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-05 | 2019-03-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-05 | 2019-03-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-05 | 2019-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-03-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-05 | 2019-03-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-03-05 | 2019-03-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-06 | 2018-07-12 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-03 | 2018-06-15 | 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 | 2018-05-03 | 2018-06-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-03 | 2018-06-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-10 | 2018-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | 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 | 2018-05-10 | 2018-06-15 | 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 ne | Health | 2018-05-10 | 2018-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-10 | 2018-06-15 | 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 | 2017-01-24 | 2017-04-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Have an externally vented heating system. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-01-24 | 2017-04-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-01-31 | 2017-04-03 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-01-31 | 2017-04-03 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-01-31 | 2017-04-03 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-31 | 2017-04-03 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-01-31 | 2017-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-01-31 | 2017-04-03 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-01-31 | 2017-04-03 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-01-31 | 2017-04-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-01-31 | 2017-04-03 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-01-31 | 2017-04-03 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-01-31 | 2017-04-03 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-01-31 | 2017-04-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-01-31 | 2017-04-03 | N |
