CMS Inspection Results for SOUTHWOOD CARE CENTER LP

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 03/10/2008 Health Survey for SOUTHWOOD CARE CENTER LP

Administration
Deficiency	Scope	Level of Harm
Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Actual harm
Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm

 

• 03/07/2008 Fire Safety Survey for SOUTHWOOD CARE CENTER LP

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
Interior Finish
Deficiency	Scope	Level of Harm
fire-resistant interior walls.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm

 

• 12/15/2006 Health Survey for SOUTHWOOD CARE CENTER LP

Administration
Deficiency	Scope	Level of Harm
Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
Keep complete, dated lab records in the resident's file.	Pattern	Minimal harm or potential for actual harm
Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Give or get dental care for each resident.	Pattern	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm

 

• 12/14/2006 Fire Safety Survey for SOUTHWOOD CARE CENTER LP

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm

 

• 09/16/2005 Health Survey for SOUTHWOOD CARE CENTER LP

Administration
Deficiency	Scope	Level of Harm
Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm
Get rid of garbage properly.	Widespread	Potential for minimal harm
Provide clean bed and bath linens that are in good condition.	Widespread	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Send and promptly deliver unopened mail to residents.	Widespread	Potential for minimal harm
Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm

 

• 09/14/2005 Fire Safety Survey for SOUTHWOOD CARE CENTER LP

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Potential for minimal harm
proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Potential for minimal harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm