A list of the most recent deficiencies for Sabetha Manor. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Meet other general requirements. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-12-06 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2022-12-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-11-15 | 2022-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-15 | 2022-12-01 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-22 | 2021-06-28 | 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 | 2021-06-22 | 2021-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-22 | 2021-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-22 | 2021-06-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-22 | 2021-06-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-09 | 2021-06-21 | 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 | 2021-06-09 | 2021-06-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-09 | 2021-06-21 | 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 | 2021-06-09 | 2021-06-21 | 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 | 2021-06-09 | 2021-06-21 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-11 | 2019-07-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-07-11 | 2019-07-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-11 | 2019-07-17 | 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 | 2019-07-11 | 2019-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-07-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-11 | 2019-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-11 | 2019-07-17 | N |
