Deficiency Records for Rayburn Health Care and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Rayburn Health Care and Rehabilitation. 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-30 | 2023-09-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-30 | 2023-09-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-30 | 2023-09-30 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-08-30 | 2023-09-30 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-08-30 | 2023-09-30 | Y |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-08-30 | 2023-09-30 | Y |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-08-30 | 2023-09-30 | Y |
| Have policies on smoking. | Health | 2023-08-30 | 2023-09-30 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-30 | 2023-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-30 | 2023-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-14 | 2022-08-30 | 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 | 2022-07-14 | 2022-08-15 | N |
| Keep all essential equipment working safely. | Health | 2022-06-28 | 2022-07-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-28 | 2022-07-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-28 | 2022-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-28 | 2022-07-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-28 | 2022-07-01 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-05-06 | 2022-05-23 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-13 | 2021-11-05 | Y |
| 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 | 2021-03-17 | 2021-04-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-17 | 2021-04-30 | 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 | 2021-03-17 | 2021-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-17 | 2021-04-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-17 | 2021-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-18 | 2021-04-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-03-18 | 2021-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-18 | 2021-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-18 | 2021-04-07 | 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 | 2021-03-18 | 2021-04-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-18 | 2021-04-07 | 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 | 2021-03-18 | 2021-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-18 | 2021-04-07 | N |