Deficiency Records for South Boston Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for South Boston Health and Rehab 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? |
|---|---|---|---|---|
| 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 | 2022-07-13 | 2022-08-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-13 | 2022-08-05 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-13 | 2022-08-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-13 | 2022-08-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-13 | 2022-07-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-13 | 2022-07-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-13 | 2022-07-03 | 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 | 2022-07-13 | 2022-07-03 | 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 | 2022-02-04 | 2022-05-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-04 | 2022-05-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-28 | 2022-03-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-28 | 2022-03-01 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-01-28 | 2022-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-28 | 2022-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2022-01-28 | 2022-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-28 | 2022-03-01 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-01-28 | 2022-03-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2022-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-03-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-01-28 | 2022-03-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-01-28 | 2022-03-01 | 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 | 2022-01-28 | 2020-06-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-10 | 2019-11-22 | 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 | 2019-10-10 | 2019-11-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-10 | 2019-11-22 | 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 | 2019-10-10 | 2019-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-10 | 2019-11-22 | N |
| Provide appropriate foot care. | Health | 2019-10-10 | 2019-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-10 | 2019-11-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-10 | 2019-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-10-10 | 2019-11-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-17 | 2018-12-17 | 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 | 2018-09-17 | 2018-11-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Have an externally vented heating system. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-17 | 2018-11-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-17 | 2018-11-01 | 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 | 2018-08-30 | 2018-10-12 | 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 | 2018-08-30 | 2018-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-30 | 2018-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-30 | 2018-10-12 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-08-30 | 2018-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-30 | 2018-10-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-30 | 2018-10-12 | 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 | 2018-08-30 | 2018-10-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-08-30 | 2018-10-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-30 | 2018-10-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-30 | 2018-10-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-30 | 2018-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-30 | 2018-10-12 | N |
