A list of the most recent deficiencies for Shawnee Care 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-22 | 2023-09-15 | 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 | 2023-08-22 | 2023-09-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-22 | 2023-09-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-22 | 2023-09-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-22 | 2023-09-15 | N |
| 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 | 2023-06-28 | 2023-08-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-06-28 | 2023-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-28 | 2023-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-28 | 2023-08-10 | 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 | 2023-06-28 | 2023-08-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-28 | 2023-08-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-28 | 2023-08-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-28 | 2023-08-10 | 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 | 2023-06-28 | 2023-08-10 | 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 | 2023-06-28 | 2023-08-10 | 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 | 2023-06-28 | 2023-08-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-28 | 2023-08-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-28 | 2023-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-08-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-08-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-28 | 2023-08-10 | Y |
| 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. | Health | 2023-06-28 | 2023-08-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-28 | 2023-08-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-29 | 2023-04-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-29 | 2023-04-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-22 | 2022-10-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-22 | 2022-10-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-22 | 2022-10-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-22 | 2022-10-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-08-22 | 2022-10-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-22 | 2022-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-22 | 2022-10-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-08-22 | 2022-10-08 | 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 | 2022-08-22 | 2022-10-08 | 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 | 2022-08-22 | 2022-10-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-22 | 2022-10-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-22 | 2022-10-08 | 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 | 2022-08-22 | 2022-10-08 | 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 | 2022-08-22 | 2022-10-08 | 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 | 2022-08-22 | 2022-10-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-22 | 2022-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-22 | 2022-10-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-22 | 2022-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-22 | 2022-10-08 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-22 | 2022-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-22 | 2022-10-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-22 | 2022-10-08 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-17 | 2022-10-08 | 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 | 2022-08-17 | 2022-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-17 | 2022-10-08 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-06-01 | 2022-08-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-01 | 2022-08-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-01 | 2022-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-01 | 2022-08-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-06 | 2019-06-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-13 | 2019-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-13 | 2019-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-13 | 2019-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-13 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-13 | 2019-06-14 | N |
