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Deficiency Records for Southpointe Rehab Center
A list of the most recent deficiencies for Southpointe Rehab Center. 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 Southpointe Rehab Center. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-23 | 2024-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-23 | 2024-08-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-23 | 2024-08-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-07-23 | 2024-08-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-17 | 2024-08-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-07-17 | 2024-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-17 | 2024-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-17 | 2024-08-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-07-17 | 2024-08-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-17 | 2024-08-12 | 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 | 2024-07-17 | 2024-08-12 | 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 | 2024-07-17 | 2024-08-12 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-07-17 | 2024-08-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-07-17 | 2024-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-17 | 2024-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-17 | 2024-08-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-17 | 2024-08-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-11 | 2023-09-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-05 | 2023-07-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-02 | 2023-06-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-02 | 2023-06-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-03-02 | 2023-06-16 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-03-02 | 2023-06-16 | 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 | 2023-03-02 | 2023-06-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-02 | 2023-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-06-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-02 | 2023-04-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-02 | 2023-04-21 | N |
| 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 | 2023-03-02 | 2023-04-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-02 | 2023-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-02 | 2023-04-21 | 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 | 2023-03-02 | 2023-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-02 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-04-21 | 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 | 2023-03-02 | 2023-04-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-02 | 2023-04-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-02 | 2023-04-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-02 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-02 | 2023-04-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-02 | 2023-04-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-03-02 | 2023-04-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-02 | 2023-04-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-02 | 2023-04-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-07 | 2023-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-20 | 2023-01-23 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-09 | 2021-12-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-23 | 2019-12-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-23 | 2019-12-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-23 | 2019-12-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | 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 | 2019-10-23 | 2019-12-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-10-23 | 2019-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-23 | 2019-12-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-23 | 2019-12-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-23 | 2019-12-07 | N |
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