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Deficiency Records for South Haven Nursing and Rehabilitation Community
A list of the most recent deficiencies for South Haven Nursing and Rehabilitation 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 South Haven Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-10-01 | 2024-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-01 | 2024-10-31 | 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 | 2024-10-01 | 2024-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-01 | 2024-10-31 | 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 | 2024-10-01 | 2024-10-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-01 | 2024-10-31 | 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 | 2024-10-01 | 2024-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-01 | 2024-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-01 | 2024-10-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-10-01 | 2024-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-10-01 | 2024-10-31 | N |
| 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 | 2024-10-01 | 2024-10-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-10-01 | 2024-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-09-26 | 2024-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-12 | 2024-05-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-12 | 2024-05-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-12 | 2024-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-12 | 2024-05-17 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-11 | 2023-11-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-18 | 2023-11-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-18 | 2023-11-20 | 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 | 2023-10-18 | 2023-11-20 | 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 | 2023-10-18 | 2023-11-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-10-18 | 2023-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-11-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-18 | 2023-11-20 | 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 | 2023-10-17 | 2023-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-17 | 2023-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-17 | 2023-11-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-02 | 2022-12-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-02 | 2022-12-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-02 | 2022-12-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-02 | 2022-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-02 | 2022-12-12 | 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 | 2022-11-02 | 2022-12-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-02 | 2022-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-02 | 2022-12-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-02 | 2022-12-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-02 | 2022-12-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-02 | 2022-12-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-02 | 2022-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2022-12-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-02 | 2022-12-12 | 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 | 2022-11-02 | 2022-12-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-02 | 2022-12-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-12 | 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 | 2022-11-02 | 2022-12-12 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-02 | 2022-12-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-02 | 2022-12-12 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-03 | 2022-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-03 | 2022-12-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-03 | 2022-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-12-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-08 | 2022-07-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-08 | 2022-07-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-08 | 2022-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-08 | 2022-07-06 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-08 | 2022-07-06 | Y |
| 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 | 2021-12-21 | 2022-02-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-21 | 2022-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-21 | 2022-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-02-07 | Y |
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