Deficiency Records for El Reno Post-Acute Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for El Reno Post-Acute Rehabilitation 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? |
|---|---|---|---|---|
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-11-03 | 2023-12-27 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-03 | 2023-12-27 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-11-03 | 2023-12-27 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-04-03 | 2023-06-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-03 | 2023-06-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-03 | 2023-06-14 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-03 | 2023-06-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-31 | 2023-06-14 | 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 | 2023-05-31 | 2023-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-31 | 2023-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-07 | 2023-02-20 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-04 | 2021-09-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-09-27 | 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 | 2019-09-04 | 2019-10-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-10 | 2019-10-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-10 | 2019-10-04 | N |
| 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 | 2019-09-10 | 2019-10-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-10 | 2019-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-10 | 2019-10-04 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-10 | 2019-10-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-10 | 2019-10-04 | 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 | 2019-09-10 | 2019-10-04 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-09-10 | 2019-10-04 | N |
| 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 | 2019-09-10 | 2019-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-09-04 | 2019-09-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-04 | 2019-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-04 | 2019-09-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-04 | 2019-09-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-08-01 | 2018-10-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-07 | 2018-08-31 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-07 | 2018-08-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-08-07 | 2018-08-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-08-07 | 2018-08-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-07 | 2018-08-31 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-01 | 2018-08-31 | N |
