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Deficiency Records for Rockwood South Hill
A list of the most recent deficiencies for Rockwood South Hill. 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 Rockwood South Hill. 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 | 2024-12-09 | 2025-01-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-12-09 | 2025-01-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-12-09 | 2025-01-15 | 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 | 2024-12-09 | 2025-01-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-12-09 | 2025-01-15 | 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 | 2024-12-09 | 2025-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-12-09 | 2025-01-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-12-09 | 2025-01-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-12-09 | 2025-01-15 | 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 | 2024-12-09 | 2025-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-09 | 2025-01-15 | 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 | 2024-12-09 | 2025-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-09 | 2025-01-15 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-12-09 | 2025-01-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-09 | 2025-01-15 | 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 | 2024-12-09 | 2025-01-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-12-09 | 2025-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-12-09 | 2025-01-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-12-09 | 2025-01-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-12-09 | 2025-01-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-12-09 | 2025-01-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-12-06 | 2025-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-06 | 2024-12-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-12-06 | 2024-12-16 | 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 | 2024-12-06 | 2024-12-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-16 | 2023-11-01 | 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 | 2023-08-03 | 2023-09-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-08-03 | 2023-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-09-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-03 | 2023-09-12 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-08-03 | 2023-09-12 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-03 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-09-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-07-26 | 2023-08-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-26 | 2022-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-23 | 2021-09-03 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-23 | 2021-09-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-23 | 2021-09-03 | 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 | 2021-07-23 | 2021-09-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-09-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-23 | 2021-09-03 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-23 | 2021-09-03 | N |
| Post nurse staffing information every day. | Health | 2021-07-23 | 2021-09-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-23 | 2021-09-03 | 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 | 2021-07-23 | 2021-09-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-23 | 2021-09-03 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-07-23 | 2021-09-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-23 | 2021-09-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-23 | 2021-09-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-23 | 2021-09-03 | N |
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