Deficiency Records for Shawnee Post Acute Rehabilitation Center
Updated as of January 01, 2021
This is not the most recent data for Shawnee Post Acute Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Shawnee Post Acute Rehabilitation Center. 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? |
|---|---|---|---|---|
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-18 | 2019-10-18 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-18 | 2019-10-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-18 | 2019-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-18 | 2019-10-18 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-18 | 2019-10-18 | 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 | 2019-09-18 | 2019-10-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-18 | 2019-10-18 | 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 | 2019-09-18 | 2019-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-18 | 2019-10-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-18 | 2019-10-18 | Y |
| Implement a program that monitors antibiotic use. | Health | 2019-09-18 | 2019-10-18 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-18 | 2019-10-18 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-09-18 | 2019-10-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-12 | 2019-07-19 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-12 | 2019-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-28 | 2019-05-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Be properly staffed | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-27 | 2019-04-12 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-12-12 | 2019-01-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-26 | 2018-08-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-26 | 2018-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-26 | 2018-08-22 | N |
| 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 | 2018-07-26 | 2018-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-26 | 2018-08-22 | 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 | 2017-12-18 | 2018-01-16 | 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 | 2017-12-18 | 2018-01-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-12-18 | 2018-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-18 | 2018-01-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2016-12-13 | 2017-01-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-12-13 | 2017-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-13 | 2017-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2016-12-13 | 2017-01-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-11-29 | 2016-12-29 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-11-29 | 2016-12-29 | N |
| 1) Hire only people with 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. | Health | 2016-11-29 | 2016-12-29 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-11-29 | 2016-12-29 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-11-29 | 2016-12-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-11-29 | 2016-12-29 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-11-29 | 2016-12-29 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-11-29 | 2016-12-29 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-11-29 | 2016-12-29 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-11-29 | 2016-12-29 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-11-29 | 2016-12-29 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-11-29 | 2016-12-29 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-11-29 | 2016-12-29 | N |
| Make sure that doctors visit residents regularly, as required. | Health | 2016-11-29 | 2016-12-29 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-11-29 | 2016-12-29 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-29 | 2016-12-29 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-11-29 | 2016-12-29 | N |
| 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation. | Health | 2016-11-29 | 2016-12-29 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2016-11-29 | 2016-12-29 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-11-29 | 2016-12-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-11-29 | 2016-12-29 | N |
