Deficiency Records for Kpc Promise Skilled Nursing Facility of Overland
Updated as of April 01, 2024
A list of the most recent deficiencies for Kpc Promise Skilled Nursing Facility of Overland. 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 gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-11-08 | 2023-12-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-08 | 2023-11-29 | 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 | 2023-11-08 | 2023-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-08 | 2023-11-29 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-27 | 2023-10-09 | N |
| 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 | 2023-09-27 | 2023-10-09 | 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 | 2023-09-27 | 2023-10-09 | 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 | 2023-09-27 | 2023-10-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-27 | 2023-10-09 | 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 | 2023-09-27 | 2023-10-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-27 | 2023-10-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-03-10 | 2022-04-09 | 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 | 2022-03-10 | 2022-04-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-10 | 2022-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-07 | 2022-03-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-07 | 2022-03-02 | 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 | 2022-02-07 | 2022-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-07 | 2022-03-02 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-07 | 2022-03-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-07 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-07 | 2022-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-06 | 2021-10-20 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-22 | 2020-02-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-22 | 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 | 2020-01-22 | 2020-02-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-03 | 2020-01-21 | N |
