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Deficiency Records for Excel Healthcare and Rehab Overland Park
A list of the most recent deficiencies for Excel Healthcare and Rehab Overland Park. 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 Overland Park. 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? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-09 | 2024-11-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-11 | 2024-10-11 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-09-11 | 2024-10-11 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-09-11 | 2024-10-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-11 | 2024-10-11 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-09-11 | 2024-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-11 | 2024-10-11 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-09-11 | 2024-10-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-11 | 2024-10-11 | 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 | 2024-09-11 | 2024-10-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-09-11 | 2024-10-11 | Y |
| 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 | 2024-09-11 | 2024-10-11 | 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 | 2024-09-11 | 2024-10-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-11 | 2024-10-11 | 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 | 2024-09-11 | 2024-10-11 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-09-11 | 2024-10-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-11 | 2024-10-11 | Y |
| 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 | 2024-09-11 | 2024-10-11 | Y |
| 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 | 2024-09-11 | 2024-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-11 | 2024-10-11 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-09-11 | 2024-10-11 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-09-11 | 2024-10-11 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-09-11 | 2024-10-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-03 | 2024-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-28 | 2024-03-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-28 | 2024-03-26 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-07 | 2023-04-07 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-10 | 2023-02-17 | 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 | 2023-01-10 | 2023-02-17 | 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 | 2023-01-10 | 2023-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-10 | 2023-02-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-05 | 2023-01-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-12-05 | 2023-01-07 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-05 | 2023-01-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-05 | 2023-01-07 | 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 | 2022-12-05 | 2023-01-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-05 | 2023-01-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-05 | 2023-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-05 | 2023-01-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-05 | 2023-01-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-05 | 2023-01-07 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-05 | 2023-01-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-05 | 2023-01-07 | 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 | 2022-12-05 | 2023-01-07 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-05 | 2023-01-07 | 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 | 2022-12-05 | 2023-01-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-08 | 2022-12-06 | 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 | 2022-10-13 | 2022-11-04 | 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 | 2022-10-31 | 2022-11-04 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-21 | 2022-04-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-21 | 2022-04-15 | 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 | 2022-01-31 | 2022-02-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-31 | 2022-02-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-11 | 2022-02-04 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-13 | 2021-06-14 | 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 | 2021-05-13 | 2021-06-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-13 | 2021-06-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-03 | 2021-06-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-03 | 2021-06-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-03 | 2021-06-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-03 | 2021-06-09 | 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 | 2021-05-03 | 2021-06-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-03 | 2021-06-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-03 | 2021-06-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-03 | 2021-06-09 | 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 | 2021-05-03 | 2021-06-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-05-03 | 2021-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-03 | 2021-06-09 | 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 | 2021-05-03 | 2021-05-03 | N |
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