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Deficiency Records for Southland
A list of the most recent deficiencies for Southland. 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 Southland. 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? |
|---|---|---|---|---|
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-06-17 | 2024-07-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-13 | 2024-05-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-29 | 2024-04-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-29 | 2024-04-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-29 | 2024-04-19 | 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 | 2024-04-19 | 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 | 2024-04-19 | 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 | 2024-03-29 | 2024-04-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-03-29 | 2024-04-19 | 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 | 2024-03-29 | 2024-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-29 | 2024-04-19 | N |
| Dispose of garbage and refuse properly. | Health | 2024-03-29 | 2024-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-29 | 2024-04-19 | 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 | 2024-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-29 | 2024-04-19 | Y |
| 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 | 2024-04-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-29 | 2024-04-19 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-04-02 | 2024-04-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-04-02 | 2024-04-19 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-04-02 | 2024-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-04-02 | 2024-04-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-04-02 | 2024-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-10 | 2024-02-01 | 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 | 2023-12-04 | 2023-12-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-28 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-28 | 2023-12-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-21 | 2023-12-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-12-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-28 | 2023-08-07 | Y |
| Keep all essential equipment working safely. | Health | 2022-05-13 | 2022-05-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-08 | 2022-04-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-08 | 2022-04-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-08 | 2022-04-29 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-04-08 | 2022-04-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-08 | 2022-04-29 | 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 | 2022-04-08 | 2022-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-08 | 2022-04-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-08 | 2022-04-29 | 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 | 2022-04-08 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-04-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-08 | 2022-04-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-08 | 2022-04-29 | 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 | 2022-04-07 | 2022-04-07 | 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 | 2022-04-07 | 2022-04-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-07 | 2022-04-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-07 | 2022-04-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-04-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-07 | 2022-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-07 | 2022-04-07 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-02-25 | 2022-03-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-09 | 2020-02-14 | 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 | 2020-01-09 | 2020-02-14 | 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 | 2020-01-09 | 2020-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-10 | 2020-02-06 | N |
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