Deficiency Records for Emporia Rehabilitation and Healthcare Center
Updated as of September 01, 2020
This is not the most recent data for Emporia Rehabilitation and Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Emporia Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-01 | 2019-06-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-05-01 | 2019-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-01 | 2019-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-01 | 2019-06-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-01 | 2019-06-25 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Develop a communication plan. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish methods for sharing information. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-18 | 2019-05-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-18 | 2019-05-29 | 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 | 2019-04-18 | 2019-05-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-18 | 2019-05-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-18 | 2019-05-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-05-29 | 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 | 2019-04-18 | 2019-05-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-18 | 2019-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-18 | 2019-05-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-18 | 2019-05-29 | 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 | 2019-04-18 | 2019-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-05-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-18 | 2019-05-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-04-18 | 2019-05-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-18 | 2019-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-18 | 2019-05-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-18 | 2019-05-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-04-18 | 2019-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-05-29 | N |
| Keep all essential equipment working safely. | Health | 2019-04-18 | 2019-05-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-16 | 2019-02-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-01-16 | 2019-02-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-16 | 2019-02-28 | Y |
| 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 | 2018-02-20 | 2018-04-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-29 | 2018-04-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-29 | 2018-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-13 | 2018-04-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-13 | 2018-04-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-13 | 2018-04-02 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-01-29 | 2018-03-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-29 | 2018-03-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-01-29 | 2018-03-05 | 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 | 2018-01-29 | 2018-03-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-29 | 2018-03-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-29 | 2018-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide activities to meet all resident's needs. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-29 | 2018-03-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-29 | 2018-03-05 | 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 | 2018-01-29 | 2018-03-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-01-29 | 2018-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-29 | 2018-03-05 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-08 | 2017-01-27 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-12-08 | 2017-01-27 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-12-08 | 2017-01-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-08 | 2017-01-27 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-12-08 | 2017-01-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-08 | 2017-01-13 | N |
| Allow residents to have visitors. | Health | 2016-12-08 | 2017-01-13 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-12-08 | 2017-01-13 | 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 | 2016-12-08 | 2017-01-13 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2016-12-08 | 2017-01-13 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-08 | 2017-01-13 | N |
| Provide adequate and comfortable lighting levels in all areas. | Health | 2016-12-08 | 2017-01-13 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-08 | 2017-01-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-12-08 | 2017-01-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-08 | 2017-01-13 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-08 | 2017-01-13 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-12-08 | 2017-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-08 | 2017-01-13 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2016-12-08 | 2017-01-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-08 | 2017-01-13 | 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 | 2016-12-08 | 2017-01-13 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-12-08 | 2017-01-13 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2016-12-08 | 2017-01-13 | N |
| Tell the attending physician the results of x-rays and other tests, in a timely manner. | Health | 2016-12-08 | 2017-01-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-08 | 2017-01-13 | N |
