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Deficiency Records for Greater Southside Health and Rehabilitation
A list of the most recent deficiencies for Greater Southside 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 Greater Southside 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? |
|---|---|---|---|---|
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2024-07-18 | 2024-07-29 | 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 | 2024-07-18 | 2024-07-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-18 | 2024-07-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-07-12 | 2024-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-12 | 2024-07-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-12 | 2024-07-23 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-07-12 | 2024-07-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-03 | 2024-06-14 | 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 | 2024-06-03 | 2024-06-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-03 | 2024-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-03 | 2024-06-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-19 | 2024-04-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-11 | 2024-04-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-11 | 2024-04-02 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-13 | 2023-10-13 | 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 | 2023-09-13 | 2023-10-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-13 | 2023-10-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-07 | 2023-10-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-07 | 2023-10-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-07 | 2023-10-11 | 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 | 2023-09-07 | 2023-10-11 | 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 | 2023-09-07 | 2023-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-13 | 2023-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-13 | 2023-10-11 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-07-13 | 2023-08-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-13 | 2023-08-02 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-07-13 | 2023-08-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-27 | 2023-08-02 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-04-27 | 2023-08-02 | 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 | 2023-04-27 | 2023-08-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-27 | 2023-08-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-27 | 2023-08-02 | 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 | 2023-04-27 | 2023-08-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-27 | 2023-08-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-08-02 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-27 | 2023-08-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-27 | 2023-06-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-27 | 2023-06-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-27 | 2023-06-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-27 | 2023-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-27 | 2023-06-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-27 | 2023-06-06 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-02-15 | 2023-03-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-15 | 2023-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-15 | 2023-03-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-02-15 | 2023-03-22 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-15 | 2023-03-22 | 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 | 2021-12-07 | 2022-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-07 | 2022-03-01 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-12-07 | 2022-01-06 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-12-07 | 2022-01-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-12-07 | 2022-01-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-07 | 2022-01-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-07 | 2022-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | N |
| 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 | 2021-12-07 | 2022-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-07 | 2022-01-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-07 | 2022-01-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-07 | 2022-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-07 | 2022-01-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-07 | 2022-01-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-07 | 2022-01-06 | N |
| Keep all essential equipment working safely. | Health | 2021-12-07 | 2022-01-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-12-07 | 2022-01-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-07 | 2022-01-06 | 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 | 2021-12-07 | 2022-01-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-07 | 2022-01-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-07 | 2022-01-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-07 | 2022-01-06 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-12-07 | 2022-01-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-04 | 2021-12-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-04 | 2021-12-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-04 | 2021-12-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-04 | 2021-12-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-04 | 2021-12-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-04 | 2021-12-02 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-11-04 | 2021-12-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-04 | 2021-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-04 | 2021-11-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-04 | 2021-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-04 | 2021-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-04 | 2021-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-04 | 2021-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-29 | Not Fixed | Y |
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