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Deficiency Records for Southfield Wellness Community
A list of the most recent deficiencies for Southfield Wellness Community. 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 Southfield Wellness Community. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-06 | 2023-12-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-06 | 2023-12-11 | 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 | 2023-11-06 | 2023-12-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-06 | 2023-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-06 | 2023-12-11 | 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 | 2023-11-06 | 2023-12-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-06 | 2023-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-06 | 2023-12-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-06 | 2023-12-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-06 | 2023-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-06 | 2023-12-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-06 | 2023-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-06 | 2023-12-11 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-06 | 2023-12-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-06 | 2023-12-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-06 | 2023-12-11 | Y |
| 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 | 2023-11-06 | 2023-12-11 | 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 | 2023-11-06 | 2023-12-11 | 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 | 2023-11-06 | 2023-12-11 | 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 | 2023-11-06 | 2023-12-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-06 | 2023-11-29 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-06 | 2023-11-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-06 | 2023-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-06 | 2023-11-29 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-09 | 2023-11-28 | 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 | 2023-11-09 | 2023-11-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-04-18 | 2023-05-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-18 | 2023-05-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-18 | 2023-05-03 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-16 | 2022-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-11 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-11 | 2022-09-11 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-11 | 2022-09-11 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-08-11 | 2022-09-11 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-16 | 2022-08-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-16 | 2022-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-16 | 2022-08-17 | 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 | 2022-08-16 | 2022-08-16 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-08-16 | 2022-08-16 | 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 | 2021-03-04 | 2021-04-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-04 | 2021-04-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-04 | 2021-04-13 | 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 | 2021-03-04 | 2021-04-13 | 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 | 2021-03-04 | 2021-04-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-04 | 2021-04-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-04 | 2021-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-04-13 | 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 | 2021-03-03 | 2021-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-03 | 2021-03-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-03 | 2021-03-12 | N |
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