A list of the most recent deficiencies for Southbrook Healthcare, Inc. 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 timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-11-02 | 2023-12-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-14 | 2022-10-21 | 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 | 2022-09-14 | 2022-10-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-14 | 2022-10-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-14 | 2022-10-21 | N |
| 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 | 2022-09-14 | 2022-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-21 | N |
| Have an externally vented heating system. | Fire Safety | 2022-09-13 | 2022-10-20 | 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 | 2022-09-13 | 2022-10-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-13 | 2022-10-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-13 | 2022-09-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-17 | 2019-11-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-17 | 2019-11-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-17 | 2019-11-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-17 | 2019-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-17 | 2019-11-14 | 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 | 2019-10-17 | 2019-11-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-17 | 2019-11-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-10-17 | 2019-11-14 | 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 | 2019-10-15 | 2019-11-14 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-10-15 | 2019-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-15 | 2019-11-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-15 | 2019-11-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-15 | 2019-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-15 | 2019-11-14 | N |
