Deficiency Records for Old Southwest Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Old Southwest Health and Rehabilitation. 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 manage his or her financial affairs. | Health | 2023-02-23 | 2023-03-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-23 | 2023-03-21 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-07 | 2023-01-10 | 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 | 2022-11-07 | 2023-01-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-07 | 2023-01-10 | 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 | 2022-11-07 | 2023-01-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-07 | 2023-01-10 | Y |
| 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 | 2022-07-29 | 2022-09-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| 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 | 2022-07-19 | 2022-08-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-19 | 2022-08-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-19 | 2022-08-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-19 | 2022-08-22 | 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 | 2022-07-19 | 2022-08-22 | 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 | 2022-07-19 | 2022-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-06-09 | 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 | 2022-02-11 | 2022-04-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-04-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-04-11 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-02-11 | 2022-03-30 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-02-11 | 2022-03-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-11 | 2022-03-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-03-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-30 | Y |
| 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 | 2022-02-11 | 2022-03-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-11 | 2022-03-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-30 | Y |
| 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 | 2021-08-11 | 2022-02-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2022-02-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-11 | 2022-02-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-11 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-11 | 2021-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-05 | 2021-10-15 | 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 | 2021-08-05 | 2021-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-10-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-10-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-05 | 2021-10-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-05 | 2021-09-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-05 | 2021-09-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-09-23 | N |
| 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 | 2021-08-05 | 2021-09-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-05 | 2021-09-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2021-08-05 | 2021-09-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-05 | 2021-09-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-05 | 2021-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-09-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-23 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-26 | 2019-07-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-26 | 2019-07-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-04-26 | 2019-07-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-26 | 2019-07-22 | 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 | 2019-04-26 | 2019-07-22 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-04-26 | 2019-07-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-26 | 2019-07-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-26 | 2019-07-22 | 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 | 2019-04-26 | 2019-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-26 | 2019-07-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-02 | 2019-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-26 | 2019-06-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-26 | 2019-06-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-26 | 2019-06-07 | N |
| 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 | 2019-04-26 | 2019-06-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-26 | 2019-06-07 | 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 | 2019-04-26 | 2019-06-07 | 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 | 2019-04-26 | 2019-06-07 | N |
| 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 | 2019-04-26 | 2019-06-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-26 | 2019-06-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-26 | 2019-06-07 | 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 | 2019-04-26 | 2019-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-26 | 2019-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-04-26 | 2019-06-07 | 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 | 2019-04-26 | 2019-06-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-04-26 | 2019-06-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-26 | 2019-06-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-26 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-26 | 2019-06-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-26 | 2019-06-07 | N |
