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Deficiency Records for Old Southwest Health and Rehabilitation
A list of the most recent deficiencies for Old Southwest 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 Old Southwest 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? |
|---|---|---|---|---|
| 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 | 2024-03-29 | 2024-08-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-29 | 2024-08-29 | 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 | 2024-03-29 | 2024-08-29 | 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 | 2024-03-29 | 2024-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-29 | 2024-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-29 | 2024-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-29 | 2024-08-29 | 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 | 2024-03-29 | 2024-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-29 | 2024-08-29 | N |
| 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 | 2024-03-29 | 2024-08-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-29 | 2024-08-29 | 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 | 2024-03-29 | 2024-08-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-29 | 2024-08-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-29 | 2024-08-29 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-03-29 | 2024-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-29 | 2024-08-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-03-29 | 2024-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-29 | 2024-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-29 | 2024-08-29 | 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 | 2024-03-29 | 2024-08-29 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-03-29 | 2024-08-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-29 | 2024-07-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-29 | 2024-07-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-29 | 2024-07-16 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-03-29 | 2024-07-16 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-03-29 | 2024-07-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-29 | 2024-07-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-29 | 2024-07-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-29 | 2024-07-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-29 | 2024-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-29 | 2024-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-29 | 2024-07-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-29 | 2024-07-16 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-29 | 2024-07-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-29 | 2024-07-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-29 | 2024-07-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-29 | 2024-07-16 | 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 | 2024-03-29 | 2024-07-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-29 | 2024-07-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-29 | 2024-07-16 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-03-29 | 2024-07-16 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-03-29 | 2024-07-16 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-29 | 2024-07-16 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-03-29 | 2024-07-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-29 | 2024-07-16 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-03-29 | 2024-07-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-29 | 2024-07-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-29 | 2024-07-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Meet other general requirements. | Fire Safety | 2024-03-29 | 2024-07-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-02-23 | 2023-03-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-23 | 2023-03-21 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-29 | 2023-02-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-07 | 2023-01-10 | 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 | 2022-11-07 | 2023-01-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-07 | 2023-01-10 | 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 | 2022-11-07 | 2023-01-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-07 | 2023-01-10 | Y |
| 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 | 2022-07-29 | 2022-09-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-29 | 2022-09-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-29 | 2022-09-12 | 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 | 2022-07-19 | 2022-08-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-19 | 2022-08-22 | 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 | 2022-07-19 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-19 | 2022-08-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-19 | 2022-08-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-19 | 2022-08-22 | 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 | 2022-07-19 | 2022-08-22 | 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 | 2022-07-19 | 2022-08-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-19 | 2022-08-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-28 | 2022-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-06-09 | 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 | 2022-02-11 | 2022-04-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-04-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-11 | 2022-04-11 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-02-11 | 2022-03-30 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-02-11 | 2022-03-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-11 | 2022-03-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-03-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-03-30 | 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 | 2022-02-11 | 2022-03-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-11 | 2022-03-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-11 | 2022-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-30 | Y |
| 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 | 2021-08-11 | 2022-02-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2022-02-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-11 | 2022-02-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-11 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-11 | 2021-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-05 | 2021-10-15 | 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 | 2021-08-05 | 2021-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-10-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-10-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-05 | 2021-10-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-05 | 2021-09-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-05 | 2021-09-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-05 | 2021-09-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-05 | 2021-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-05 | 2021-09-23 | N |
| 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 | 2021-08-05 | 2021-09-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | 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 | 2021-08-05 | 2021-09-23 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2021-08-05 | 2021-09-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-05 | 2021-09-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-05 | 2021-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-11 | 2021-09-21 | N |
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