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Inspection visit

Inspection

Southpoint Rehabilitation and Healthcare CenterCMS #34540822 citations on this visit
22 citations recorded

Citations

22 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0661GeneralS&S Dpotential for harm

    F661 - Quality of life

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  • 0554GeneralS&S Dpotential for harm

    F554 - The right to self-administer medications if the interdisciplinary team, as

    Allow residents to self-administer drugs if determined clinically appropriate.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    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.

  • 0600SeriousS&S Jimmediate jeopardy

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0660GeneralS&S Dpotential for harm

    F660 - Quality of life

    Plan the resident's discharge to meet the resident's goals and needs.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0684SeriousS&S Jimmediate jeopardy

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0726SeriousS&S Jimmediate jeopardy

    F726 - Nursing Services

    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.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0809GeneralS&S Epotential for harm

    F809 - Frequency of Meals

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  • 0867GeneralS&S Epotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0161GeneralS&S Dpotential for harm

    Use approved construction type or materials.

  • 0211GeneralS&S Dpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372GeneralS&S Dpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0914GeneralS&S Dpotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

FAQ · About this visit

Common questions about this visit

What happened during the April 5, 2024 survey of Southpoint Rehabilitation and Healthcare Center?

This was a inspection survey of Southpoint Rehabilitation and Healthcare Center on April 5, 2024. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Southpoint Rehabilitation and Healthcare Center on April 5, 2024?

Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planne..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.