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 |