Deficiency Records for South Pointe Rehabilitation and Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for South Pointe Rehabilitation and Care 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-17 | 2024-02-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-17 | 2024-02-14 | 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 | 2024-01-17 | 2024-02-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-17 | 2024-02-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-17 | 2024-02-14 | 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 | 2024-01-17 | 2024-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-17 | 2024-02-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-17 | 2024-02-14 | 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 | 2024-01-17 | 2024-02-14 | N |
| Post nurse staffing information every day. | Health | 2024-01-17 | 2024-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-17 | 2024-02-14 | 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 | 2024-01-17 | 2024-02-14 | 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 | 2024-01-17 | 2024-02-14 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-01-17 | 2024-02-14 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-01-17 | 2024-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-17 | 2024-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-17 | 2024-02-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-17 | 2024-02-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-17 | 2024-02-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-17 | 2024-02-14 | 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 | 2024-01-10 | 2024-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-10 | 2024-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-10 | 2024-02-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-10 | 2024-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-02 | 2023-05-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-05-10 | 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 | 2023-04-19 | 2023-04-27 | 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 | 2023-04-19 | 2023-04-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-19 | 2023-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-19 | 2023-04-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-19 | 2023-04-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-20 | 2022-02-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-02-16 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-06-22 | 2021-06-23 | 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 | 2021-06-22 | 2021-06-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-22 | 2021-06-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-22 | 2021-06-23 | 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 | 2021-06-22 | 2021-06-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-22 | 2021-06-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-22 | 2021-06-23 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-06-22 | 2021-06-23 | 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 | 2021-06-22 | 2021-06-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-22 | 2021-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-22 | 2021-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-22 | 2021-06-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-22 | 2021-06-23 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-22 | 2021-06-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-22 | 2021-06-23 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-06-22 | 2021-06-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-22 | 2021-06-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-22 | 2021-06-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-22 | 2021-06-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-22 | 2021-06-23 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-22 | 2021-06-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-22 | 2021-06-09 | 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 | 2021-04-22 | 2021-05-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-22 | 2021-05-11 | 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 | 2021-04-22 | 2021-05-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-04-22 | 2021-04-28 | N |
