Deficiency Records for Llano Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Llano Nursing and 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-01-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-15 | 2023-12-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-16 | 2023-08-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-04-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-02 | 2023-04-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-02 | 2023-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-02 | 2023-04-03 | 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 | 2022-10-03 | 2022-10-04 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-04-28 | 2022-04-29 | Y |
| 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 | 2022-04-28 | 2022-04-29 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-28 | 2022-04-29 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-04-28 | 2022-04-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-28 | 2022-04-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-28 | 2022-04-29 | 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 | 2022-04-28 | 2022-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-28 | 2022-04-29 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-07 | 2019-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-07 | 2019-09-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-07 | 2019-09-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-08-07 | 2019-09-04 | 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 | 2019-08-07 | 2019-09-04 | N |
| Post nurse staffing information every day. | Health | 2019-08-07 | 2019-09-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-07 | 2019-09-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-07 | 2019-09-04 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-08-07 | 2019-09-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-07 | 2019-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-29 | 2018-10-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-31 | 2018-10-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-31 | 2018-09-30 | 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 | 2018-08-31 | 2018-09-30 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2018-08-31 | 2018-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-29 | 2018-09-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-29 | 2018-09-19 | 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 | 2018-08-31 | 2018-09-14 | 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 | 2018-08-31 | 2018-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-31 | 2018-09-01 | N |
| Dispose of garbage and refuse properly. | Health | 2018-08-31 | 2018-09-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-31 | 2018-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-31 | 2018-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-29 | 2018-08-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-29 | 2018-08-30 | N |
