Elk City Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Elk City Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF642Mar 20, 2024

  Based on record review and interview, the facility failed to ensure a registered nurse coordinated and signed resident assessments prior to submission to CMS. The DON reported 51 residents resided in the facility. Findings: A Clinical - MDS list, dated 12/02/23 through 03/18/24, documented 112 assessments had been submitted to CMS and accepted. On 03/20/24 at 2:38 p.m., the MDS coordinator reported being a licensed practical nurse not a registered nurse. The MDS coordinator reported she had signed all the assessments that were submitted to CMS between 12/02/23 through 03/18/24. On 03/20/24 2:40 p.m., the DON reported the facility did not have a policy related to completing and submitting MDS assessments. […]

• No harm, potential for more than minimal, patternF582Mar 20, 2024

  Based on record review and interview the facility failed to provide timely and complete beneficiary notices to three (#51, #16, #109) of three sampled residents reviewed for beneficiary notices. The Administrator identified 51 residents resided in the facility. Findings: An undated Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 policy, read in part, .The provider must ensure that the beneficiary or representative signs and dated the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . […]

• No harm, potential for more than minimal, patternF656Mar 20, 2024

  Based on record review, interview the facility failed to develop a comprehensive care plan related to hospice, antipsychotic, anticoagulant, and opioid medications for two residents (#14 and #46) of 13 sampled residents reviewed for care plans. The Administrator identified 51 residents resided in the facility. Findings: 1. Resident #14 had diagnosis which included Dementia, depression, and pain. Facility had no Care Plan policy until 03/19/24. A care plan, dated 11/30/22, documented no focused area's for antipsychotic, anticoagulant, and opiod medications on the comprehensive care plan. On 03/19/24 at 11:34 a.m., the MDS Coordinator #1 was asked What the policy was for developing a comprehensive care plan. […]

• No harm, potential for more than minimal, patternF657Mar 20, 2024

  Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after each assessment for two (#31 and #36) of 13 residents whose care plans were reviewed. The administrator identified 51 residents resided in the facility. Findings: 1. Resident #31 was admitted with diagnoses which included non-Alzheimer's dementia, dementia with other behavioral disturbance, and depression A care plan, revised 09/13/23, documented [name removed] has a mood problem r/t depression. […]

• No harm, potential for more than minimal, patternF880Mar 20, 2024

  Based on observation, record review, and interview, the facility failed to ensure staff maintained infection control measures when passing medications. The Administrator identifed 51 residents resided in the facility. Findings: A Policy and Procedure, dated 03/04/21, read in part, .Precautions are utilized to prevent and control transmission of infectious organisms through direct and indirect contact .Hand hygiene means cleaning your hands by using either handwashing .antiseptic hand wash .antiseptic hand rub .medication preparation areas .Proper cleaning/disinfection of resident care care equipment including equipment shared among residents . On 03/19/24 at 7:32 a.m., CMA #2 obtained a blood pressure with a manual cuff and stethoscope on Resident #15. […]