A list of the most recent deficiencies for Talihina 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? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-01 | 2024-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-01 | 2024-03-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-01 | 2024-03-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-01 | 2024-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-01 | 2024-03-18 | 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 | 2024-03-01 | 2024-03-18 | N |
| 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 | 2024-03-01 | 2024-03-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-03-01 | 2024-03-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-01 | 2024-03-18 | 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 | 2024-03-01 | 2024-03-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-01 | 2024-03-18 | 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 | 2024-03-01 | 2024-03-18 | 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 | 2024-03-01 | 2024-03-18 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2024-03-01 | 2024-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-01 | 2024-03-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-09 | 2023-05-23 | 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 | 2023-02-17 | 2023-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-09 | 2023-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-15 | 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 | 2023-02-17 | 2023-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-27 | 2022-02-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-02-21 | 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 | 2022-01-27 | 2022-02-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-27 | 2022-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-27 | 2022-02-21 | 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 | 2022-01-27 | 2022-02-21 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-27 | 2022-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-02-21 | 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 | 2022-01-25 | 2022-02-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-25 | 2022-01-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-07 | 2021-12-31 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-20 | 2019-09-04 | 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 | 2019-08-20 | 2019-08-23 | N |
