Deficiency Records for Southwestern Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Southwestern Nursing and 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-15 | 2024-02-06 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-12-15 | 2024-02-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-15 | 2024-02-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-15 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-15 | 2024-02-06 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-12-15 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2024-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-15 | 2024-02-06 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-12-15 | 2024-02-06 | 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 | 2023-12-15 | 2024-02-06 | 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 | 2023-12-15 | 2024-02-06 | 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 | 2023-12-15 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-02-06 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-15 | 2024-02-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-15 | 2024-02-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Meet other general requirements. | Fire Safety | 2023-12-11 | 2024-01-30 | 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 | 2023-12-11 | 2024-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-11 | 2024-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-06 | 2023-06-27 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-06-06 | 2023-06-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-21 | 2023-05-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-11 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-16 | 2023-04-20 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-02-12 | 2023-03-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-12 | 2023-03-20 | 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 | 2023-02-12 | 2023-03-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-12 | 2023-03-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-12 | 2023-03-20 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-02-12 | 2023-03-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-12 | 2023-03-20 | 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 | 2023-02-12 | 2023-03-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-12 | 2023-03-20 | 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 | 2023-02-12 | 2023-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-12 | 2023-03-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-02-12 | 2023-03-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-12 | 2023-03-20 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-02-12 | 2023-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-16 | 2023-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-29 | 2023-01-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-09 | 2022-12-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-09 | 2022-12-07 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-11-09 | 2022-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-20 | 2022-10-06 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-20 | 2022-10-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-20 | 2022-10-06 | Y |
| 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 | 2022-09-20 | 2022-10-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-23 | 2022-09-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-23 | 2022-09-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-30 | 2022-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-30 | 2022-07-11 | 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 | 2022-06-09 | 2022-06-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-09 | 2022-06-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-09 | 2022-06-29 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-09 | 2022-06-29 | Y |
| 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 | 2022-06-09 | 2022-06-29 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-05-02 | 2022-06-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-02 | 2022-06-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-02 | 2022-06-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-02 | 2022-06-09 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-02 | 2022-06-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-02 | 2022-06-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-05-02 | 2022-06-09 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-04 | 2022-05-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-04 | 2022-05-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-05-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-04 | 2022-05-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-04 | 2022-05-16 | Y |
| Keep all essential equipment working safely. | Health | 2022-04-04 | 2022-05-16 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-01-22 | 2022-02-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-22 | 2022-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-22 | 2022-02-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-22 | 2022-02-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-22 | 2022-02-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-22 | 2022-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-22 | 2022-02-22 | 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 | 2022-01-22 | 2022-02-22 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-22 | 2022-02-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-22 | 2022-02-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-04 | 2022-02-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-04 | 2022-02-01 | 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 | 2022-01-04 | 2022-02-01 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-01-04 | 2022-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-04 | 2022-02-01 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-10-21 | 2021-10-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-17 | 2021-10-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-09-17 | 2021-10-19 | Y |
| 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 | 2021-09-17 | 2021-10-19 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-17 | 2021-10-19 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-17 | 2021-10-19 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-17 | 2021-10-19 | Y |
| 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 | 2021-08-20 | 2021-09-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-20 | 2021-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-06 | 2021-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-16 | 2021-05-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-16 | 2021-05-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-16 | 2021-05-18 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-16 | 2021-05-18 | Y |
