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Deficiency Records for Excel Healthcare and Rehab Wichita
A list of the most recent deficiencies for Excel Healthcare and Rehab Wichita. 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 Excel Healthcare and Rehab Wichita. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-06-24 | 2024-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-24 | 2024-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-11 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-08 | 2023-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-08 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-08 | 2023-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-08 | 2023-09-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-29 | 2023-07-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-06-29 | 2023-07-28 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2023-06-29 | 2023-07-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-07-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-29 | 2023-07-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-29 | 2023-07-28 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-29 | 2023-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-28 | Y |
| 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 | 2023-06-29 | 2023-07-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-29 | 2023-07-28 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-29 | 2023-07-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-28 | 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 | 2022-06-08 | 2022-07-08 | 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 | 2022-06-08 | 2022-07-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-08 | 2022-07-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-08 | 2022-06-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-21 | 2022-05-18 | Y |
| 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 | 2022-04-21 | 2022-05-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-21 | 2022-05-18 | Y |
| 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 | 2022-04-21 | 2022-05-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-21 | 2022-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-21 | 2022-05-18 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-04-21 | 2022-05-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| 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 | 2021-09-16 | 2021-10-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-16 | 2021-10-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-16 | 2021-09-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-16 | 2021-09-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-11 | 2021-09-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-11 | 2021-09-11 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-08-11 | 2021-09-11 | N |
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