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Deficiency Records for Big Horn Rehabilitation and Care Center
A list of the most recent deficiencies for Big Horn Rehabilitation and Care Center. 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 Big Horn Rehabilitation and Care Center. 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? |
|---|---|---|---|---|
| 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 | 2024-04-04 | 2024-05-25 | 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 | 2024-04-04 | 2024-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-04 | 2024-05-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-04 | 2024-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-04 | 2024-04-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-04-04 | 2024-04-10 | 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 | 2024-04-04 | 2024-04-10 | 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 | 2024-04-04 | 2024-04-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-21 | 2023-12-21 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-10-05 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-10-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-05 | 2023-10-27 | 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 | 2023-10-03 | 2023-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-03 | 2023-10-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-12 | 2023-05-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-08 | 2023-03-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-02-08 | 2023-03-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-08 | 2023-03-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-02-08 | 2023-03-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-08 | 2023-03-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-08 | 2023-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-01 | N |
| Post nurse staffing information every day. | Health | 2023-02-08 | 2023-03-01 | 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 | 2023-02-08 | 2023-03-01 | 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 | 2023-02-08 | 2023-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-08 | 2023-03-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-08 | 2023-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-08 | 2023-03-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-08 | 2023-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-08 | 2023-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-08 | 2023-02-28 | 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 | 2023-02-08 | 2023-02-28 | 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 | 2023-02-08 | 2023-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-02-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-08 | 2023-02-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-08 | 2023-02-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-08 | 2023-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-08 | 2023-02-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-02 | 2022-09-05 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-02 | 2022-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-02 | 2022-09-05 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-18 | 2022-04-13 | 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 | 2021-11-18 | 2021-12-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-27 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-18 | 2021-12-27 | Y |
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