Health inspection·July 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described services that attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. : The facility failed to ensure a Care Plan was developed to address Resident #2's dry skin (skin was not falling off the body the way it should). This failure could place residents at risk of not receiving individualized care and services to meet their needs. The findings include:Record review of Resident #2's admission Record, dated 7/23/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Vitamin D deficiency (deficiency that may cause skin to become dry and flakey) and Diabetes (a condition where the body cannot regulate its blood sugar effectively). Record review of Resident #2's Quarterly MDS Assessment, dated 4/23/25, revealed:He scored an 8 of 15 on his Brief Mental Status exam, which indicated he was moderately cognitively impaired.Resident #2 did not receive any Skin Treatments. Record review of Resident #2's Order Summary, dated 7/23/25, revealed an order dated 6/6/25 for lotion to bilateral (both sides) upper extremities every day. Record review of Resident #2's Care Plan, last updated 4/30/25, revealed no care plan for the order of lotion. Observation and interview on 07/22/2025 at 11:31 AM revealed Resident #2 in the dining room. Resident #2's cheeks were covered with flakes of dead skin build up. Resident #2 stated it was just old man stuff. The resident stated he didn't like to take shower. Interview on 07/24/2025 at 9:45 AM, the DON said Resident #2 had dry-skin scales all over his face and arms and used regular lotion to soften it. The DON stated it helped, but Resident #2 did not like to take showers. The DON said Resident #2 had a diagnosis of seborrheic keratosis, which meant the skin did not want to detach the way it should. The DON said Resident #2 stated he had a history of skin cancer years ago, but she did not follow up with Resident #2's responsible party to confirm that the information. The DON stated it did not look like Resident #2's skin condition was care planned. The DON said if the facility was doing the lotion as a treatment it should be care planned. The DON stated she had been at the facility six weeks and had not had a chance to review charts, so she did not know why the care plan was missed. The DON said the order for the lotion was signed on 6/8/25 so the facility had a month to get it into the care plan. Interview on 07/24/2025 at 11:07 AM, the MDS Coordinator stated after 14 days of admission she was responsible for the initial care plan and any MDS update. The MDS Coordinator stated the DON was responsible for putting in acute care plans which was anything between the MDS cycles. The MDS Coordinator stated the facility had Standards of Care meetings where doctor orders were discussed. The MDS Coordinator stated frequently the computer was in with the nurses at the Page 1 of 3 455737 455737 07/24/2025 Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Standards of Care meeting so they would put it in the computer at the time of the meeting. The MDS Coordinator stated she would expect a standing order to be care planned if the lotion was ordered 6/6/25. The MDS Coordinator stated she did not know why the care plan was missed. The MDS Coordinator stated she felt the care plan process was effective because the facility did not have a DON for a long time. The MDS Coordinator said the ADON would go to morning meetings and bring up changes in resident conditions in the morning meetings. Record review of the facility's policy and procedure on Comprehensive Care Planning, undated, revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 455737 Page 2 of 3 455737 07/24/2025 Concho Health & Rehabilitation Center 613 Eaker St Eden, TX 76837

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #7) of two residents reviewed for infection control practices. LVN A failed to sanitize the glucometer with a germicidal wipe after she performed a blood sugar check on Resident #7. This failure could affect the residents by placing them at risk for the spread of infection. Finding include: Record review of Resident #7's admission record, dated 07/24/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included diabetes mellitus type 2 and chronic kidney disease. Record review of Resident #7's Medication Order summary, dated 07/24/25, revealed she received Insulin Solution (Insulin Asp art) subcutaneously before meals and at bedtime per sliding scale related to type 2 diabetes mellitus. During an observation and interview on 07/23/2025 at 4:14 PM, revealed LVN A used a glucometer to perform a blood sugar check on Resident #7 in her room. After the nurse checked the resident's blood sugar she went to her medication cart, cleaned and sanitized the glucometer with an alcohol prep pad. LVN A said she normally used alcohol prep pads to clean and sanitize the glucometer. She said as far as she knew that was an acceptable way to sanitize the glucometer. During an interview on 07/23/2025 at 4:55 PM, the DON said the nurse was not supposed to use an alcohol prep pad but instead they were supposed to use the germicidal wipes. The DON said if the nurse did not use the germicidal wipes it could lead to cross contamination and the spread of infections. The DON said she had not noticed the nurses not using the germicidal wipes and would be conducting more training. During an interview on 07/24/2025 at 3:46 PM, the Administrator said the nurse should have used the germicidal type of wipe to sanitize the glucometer to properly sanitize the glucometer. She said the germicidal was used to spread of germs and infections. Review of the facility's, undated, policy titled Glucometer indicated in part: Maintenance 2. Meter will be cleaned with a germicidal and allowed to air dry between patient testings. Residents Affected - Few 455737 Page 3 of 3