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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? |
|---|---|---|---|---|
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-19 | 2021-11-08 | 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-12-03 | 2021-02-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-08-17 | 2020-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-08-17 | 2020-09-24 | 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 | 2020-08-17 | 2020-09-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-08-17 | 2020-09-24 | N |
| Provide activities to meet all resident's needs. | Health | 2020-08-17 | 2020-09-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-17 | 2020-09-24 | 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 | 2020-08-17 | 2020-09-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-08-17 | 2020-09-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-08-17 | 2020-09-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-08-17 | 2020-09-24 | 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 | 2020-08-17 | 2020-09-24 | 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 | 2020-08-17 | 2020-09-24 | N |
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