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Deficiency Records for Kiowa Hills Rehabilitation and Nursing LLC
A list of the most recent deficiencies for Kiowa Hills Rehabilitation and Nursing LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Kiowa Hills Rehabilitation and Nursing LLC. 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 | 2024-01-02 | 2024-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-02 | 2024-03-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-02 | 2024-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-02 | 2024-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-02 | 2024-03-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-07 | 2024-02-28 | 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 | 2023-12-07 | 2024-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2024-02-28 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-07 | 2024-02-28 | N |
| 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 | 2023-12-07 | 2024-02-28 | 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 | 2023-12-07 | 2024-02-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-07 | 2024-02-28 | 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 | 2023-12-07 | 2024-02-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-07 | 2024-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-02-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-07 | 2024-02-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-07 | 2024-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-02-28 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-12-07 | 2024-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2024-02-28 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-07 | 2024-02-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-12-07 | 2024-02-28 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-07 | 2024-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-02 | 2024-01-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-18 | 2023-10-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-18 | 2023-10-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-18 | 2023-10-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-18 | 2023-10-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-13 | 2023-01-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-06 | 2022-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-06 | 2022-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-06 | 2022-11-15 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-08-25 | 2022-09-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-08-25 | 2022-09-28 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-08-25 | 2022-09-28 | 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 | 2022-08-25 | 2022-09-28 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide appropriate foot care. | Health | 2022-08-25 | 2022-09-28 | 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 | 2022-08-25 | 2022-09-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-28 | 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 | 2022-08-25 | 2022-09-28 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-25 | 2022-09-28 | 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 | 2022-08-25 | 2022-09-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-25 | 2022-09-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-08-25 | 2022-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-25 | 2022-09-28 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-25 | 2022-09-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-08-25 | 2022-09-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-25 | 2022-09-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-25 | 2022-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-30 | 2021-08-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-17 | 2021-07-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-17 | 2021-07-16 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-06-17 | 2021-07-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-17 | 2021-07-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-17 | 2021-07-16 | 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 | 2021-06-30 | 2021-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-30 | 2021-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-06 | Not Fixed | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-06 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-06 | Not Fixed | N |
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