Deficiency Records for Southpointe Care and Rehab Center LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Southpointe Care and Rehab Center LLC. 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? |
|---|---|---|---|---|
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-07-28 | 2024-02-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-17 | 2023-09-13 | 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 | 2023-08-17 | 2023-09-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-17 | 2023-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-17 | 2023-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-09-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-17 | 2023-09-13 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-28 | 2023-09-11 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-06-30 | 2022-07-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-30 | 2022-07-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-30 | 2022-07-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-07-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-30 | 2022-07-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-07 | 2022-07-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-07 | 2022-07-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-07 | 2022-07-30 | 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 | 2022-04-07 | 2022-06-30 | 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 | 2022-04-07 | 2022-06-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-07 | 2022-06-30 | 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 | 2022-04-07 | 2022-06-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-07 | 2022-06-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-07 | 2022-06-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-07 | 2022-06-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-04-07 | 2022-06-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-04-07 | 2022-06-30 | 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 | 2022-04-07 | 2022-06-30 | 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 | 2022-04-07 | 2022-06-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-07 | 2022-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-06-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-07 | 2022-06-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-07 | 2022-06-30 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-07 | 2022-06-30 | 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 | 2022-04-07 | 2022-06-30 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-07 | 2022-06-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-07 | 2022-06-30 | Y |
| 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 | 2022-04-07 | 2022-06-30 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-07 | 2022-06-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-06-30 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-07 | 2022-06-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-07 | 2022-06-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-07 | 2022-06-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-07 | 2022-06-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-06-30 | 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 | 2022-03-23 | 2022-05-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-23 | 2022-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-23 | 2022-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-23 | 2022-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-02-16 | 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 | 2022-01-12 | 2022-02-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-12 | 2022-02-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-12 | 2022-02-09 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-01-12 | 2022-02-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-27 | 2021-11-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-27 | 2021-11-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-13 | 2021-11-09 | 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 | 2021-10-13 | 2021-11-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-13 | 2021-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-13 | 2021-11-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-13 | 2021-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-11-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-13 | 2021-11-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-13 | 2021-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-09-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-12 | 2021-06-12 | 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 | 2021-05-12 | 2021-06-12 | 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 | 2021-04-07 | 2021-05-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-05-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-05-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-05 | 2020-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-05 | 2020-04-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-05 | 2020-04-07 | 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 | 2020-03-05 | 2020-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-05 | 2020-04-07 | 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 | 2020-03-05 | 2020-04-07 | 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 | 2020-03-05 | 2020-04-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-05 | 2020-04-07 | 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 | 2020-03-05 | 2020-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-04-07 | N |
