Deficiency Records for Emporia Rehabilitation and Healthcare Center
Updated as of April 01, 2024
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-16 | 2023-12-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-16 | 2023-12-19 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-16 | 2023-12-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-16 | 2023-12-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-16 | 2023-12-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-16 | 2023-12-19 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-16 | 2023-12-19 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-16 | 2023-12-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-16 | 2023-12-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-16 | 2023-12-19 | 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 | 2023-10-16 | 2023-12-19 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-31 | 2023-04-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-23 | 2023-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-23 | 2023-01-03 | N |
| Meet fire sprinkler requirement for tall buildings. | Fire Safety | 2022-11-23 | 2023-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-23 | 2023-01-03 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-11-16 | 2022-12-30 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-11-16 | 2022-12-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-16 | 2022-12-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-16 | 2022-12-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-16 | 2022-12-30 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-11-16 | 2022-12-30 | 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 | 2022-11-16 | 2022-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-16 | 2022-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-16 | 2022-12-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-16 | 2022-12-30 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-16 | 2022-12-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-16 | 2022-12-30 | 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 | 2022-11-16 | 2022-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-16 | 2022-12-30 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-16 | 2022-12-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-16 | 2022-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-08 | 2022-07-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-16 | 2022-01-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-01-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-16 | 2022-01-17 | Y |
| Keep all essential equipment working safely. | Health | 2021-12-16 | 2022-01-17 | Y |
| 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 |
| 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 |
| 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 |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-20 | 2018-07-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-20 | 2018-07-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-02-20 | 2018-07-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-20 | 2018-07-09 | N |
| Have an externally vented heating system. | Fire Safety | 2018-02-20 | 2018-07-09 | 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 |
| 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 requirements for the use of electrical equipment. | Fire Safety | 2018-02-20 | 2018-04-10 | N |
| 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 |
