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Deficiency Records for Southwell Health and Rehabilitation
A list of the most recent deficiencies for Southwell Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Southwell 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-09-13 | 2024-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-13 | 2024-10-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-09-13 | 2024-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2024-09-13 | 2024-10-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-13 | 2024-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-13 | 2024-10-28 | 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 | 2024-09-13 | 2024-10-28 | 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 | 2024-09-13 | 2024-10-28 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-09-13 | 2024-10-28 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-09-13 | 2024-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-23 | 2024-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-23 | 2024-10-28 | 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 | 2023-11-30 | 2024-01-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-23 | 2023-05-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-23 | 2023-05-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-05-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-05-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-27 | 2022-12-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-27 | 2022-12-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-27 | 2022-12-11 | Y |
| 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 | 2022-10-27 | 2022-12-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-12-11 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-27 | 2022-11-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-12-18 | 2020-02-01 | N |
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