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Deficiency Records for Southview Manor
A list of the most recent deficiencies for Southview Manor. 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 Southview Manor. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-05 | 2024-10-01 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-09-05 | 2024-10-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-09-05 | 2024-10-01 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-09-05 | 2024-10-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-26 | 2024-08-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-26 | 2024-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-08-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-26 | 2024-08-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-04 | 2024-08-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-05 | 2024-07-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-05 | 2024-07-04 | 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 | 2024-06-05 | 2024-07-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-05 | 2024-07-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-05 | 2024-07-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-06-05 | 2024-07-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-05 | 2024-07-04 | 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 | 2024-06-05 | 2024-07-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-05 | 2024-07-04 | 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 | 2024-06-05 | 2024-07-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-05 | 2024-07-04 | N |
| Dispose of garbage and refuse properly. | Health | 2024-06-05 | 2024-07-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-05 | 2024-07-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-05 | 2024-07-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-06-05 | 2024-07-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-04 | 2024-07-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-10 | 2024-05-06 | 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 | 2024-04-10 | 2024-05-06 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-04-10 | 2024-05-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-10 | 2024-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-10 | 2024-05-06 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-04-10 | 2024-05-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-15 | 2024-04-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-26 | 2024-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-26 | 2024-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-08 | 2024-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-08 | 2024-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-10 | 2024-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-10 | 2024-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-18 | 2024-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-21 | 2024-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-21 | 2024-01-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-08 | 2023-12-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-08 | 2023-12-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-08 | 2023-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-08 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-18 | 2023-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-21 | 2023-12-08 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-02 | 2023-10-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-08-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-08-02 | 2023-08-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-21 | 2023-08-11 | 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 | 2023-07-21 | 2023-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-21 | 2023-08-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-21 | 2023-08-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-21 | 2023-08-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-02 | 2023-08-11 | 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 | 2023-08-02 | 2023-08-11 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-02 | 2023-08-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-08-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-21 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-21 | 2023-05-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-21 | 2023-05-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-04 | 2022-11-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-17 | 2022-11-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-17 | 2022-11-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-23 | 2022-10-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-23 | 2022-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-23 | 2022-10-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-23 | 2022-10-14 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-17 | 2022-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2022-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-17 | 2022-09-15 | 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 | 2022-08-17 | 2022-09-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-17 | 2022-09-15 | 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 | 2022-08-17 | 2022-09-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-08-17 | 2022-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-17 | 2022-09-15 | 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 | 2022-08-12 | 2022-09-02 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-08-12 | 2022-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-12 | 2022-09-02 | 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 | 2022-08-12 | 2022-09-02 | 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 | 2022-08-12 | 2022-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-12 | 2022-09-02 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-12 | 2022-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-09-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-05 | 2022-08-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-29 | 2022-07-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-02 | 2022-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-11 | 2022-04-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-08 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-04-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-14 | 2022-02-11 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-01-14 | 2022-02-11 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-14 | 2022-02-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-12-08 | 2021-12-20 | Y |
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