Deficiency Records for Topeka Center For Rehabilitation and Healthcare
Updated as of March 01, 2024
A list of the most recent deficiencies for Topeka Center For Rehabilitation and Healthcare. 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? |
|---|---|---|---|---|
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-12-19 | 2024-01-25 | 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 | 2023-12-19 | 2024-01-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-19 | 2024-01-25 | 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 | 2023-12-19 | 2024-01-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-19 | 2024-01-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-30 | 2024-01-12 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-30 | 2024-01-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-11-30 | 2024-01-12 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-30 | 2024-01-12 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-30 | 2024-01-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-30 | 2024-01-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-30 | 2024-01-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-30 | 2024-01-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-30 | 2024-01-12 | Y |
| 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 | 2023-11-30 | 2024-01-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2024-01-12 | Y |
| 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 | 2023-11-30 | 2024-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2024-01-12 | 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 | 2023-11-30 | 2024-01-12 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-30 | 2024-01-12 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-30 | 2024-01-12 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-30 | 2024-01-12 | 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 | 2023-11-30 | 2024-01-12 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-30 | 2024-01-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-30 | 2024-01-12 | Y |
| 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 | 2023-11-30 | 2024-01-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-01-12 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-30 | 2024-01-12 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-30 | 2024-01-12 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-30 | 2024-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2023-11-02 | Y |
| 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 | 2023-11-30 | 2023-11-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Meet other general requirements. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-19 | 2023-08-08 | 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 | 2023-07-19 | 2023-08-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-19 | 2023-08-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-31 | 2023-07-13 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-31 | 2023-07-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-31 | 2023-07-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-31 | 2023-07-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-31 | 2023-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-31 | 2023-07-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-31 | 2023-07-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-31 | 2023-07-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-31 | 2023-07-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-31 | 2023-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-31 | 2023-07-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-31 | 2023-07-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-31 | 2023-07-13 | 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 | 2023-05-31 | 2023-07-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-04-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-08 | 2023-03-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-08 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-07 | 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 | 2023-02-08 | 2023-03-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-08 | 2023-03-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-08 | 2023-03-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-08 | 2023-03-07 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-08 | 2023-03-07 | Y |
| 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 | 2023-02-08 | 2023-03-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-13 | 2023-01-24 | 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 | 2022-12-13 | 2023-01-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-13 | 2023-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-21 | 2022-12-19 | 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 | 2022-11-21 | 2022-12-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-21 | 2022-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-21 | 2022-12-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-21 | 2022-12-19 | 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 | 2022-11-21 | 2022-12-19 | Y |
| 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 | 2022-11-21 | 2022-12-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-21 | 2022-12-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-21 | 2022-12-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-21 | 2022-12-19 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-21 | 2022-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2022-12-19 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-21 | 2022-12-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-13 | 2022-12-14 | 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 | 2022-06-16 | 2022-09-26 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-16 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-16 | 2022-08-31 | 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 | 2022-06-16 | 2022-08-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-16 | 2022-08-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-16 | 2022-08-31 | Y |
| 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 | 2022-06-16 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-07-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-06-16 | 2022-07-14 | 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 | 2022-06-16 | 2022-07-14 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-16 | 2022-07-14 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-06-16 | 2022-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-16 | 2022-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-16 | 2022-07-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-16 | 2022-07-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-17 | 2022-04-18 | Y |
| 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 | 2022-03-07 | 2022-03-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-22 | 2022-01-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-27 | 2021-11-20 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-10-27 | 2021-11-20 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-13 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-15 | 2021-08-13 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-15 | 2021-08-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-15 | 2021-08-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-15 | 2021-08-13 | Y |
| 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 | 2021-07-15 | 2021-08-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-15 | 2021-08-13 | Y |
| 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 | 2021-07-15 | 2021-08-13 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-05-03 | 2021-06-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-03 | 2021-06-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-08 | 2021-04-30 | Y |
