Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents
reviewed for care plans. (Resident #1)
The facility failed to implement the comprehensive person-centered care plan for Resident #1 by not having
a fall mat beside the bed when the resident fell.
This failure could place residents at risk of not having individual needs met, a decreased quality of life, and
cause residents not to receive needed services.
Findings include:
Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted
on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart
failure, and anxiety.
Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which
indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for
assistance with ADLs. The MDS indicated Resident #1 had not had any falls since admission .
Record review of a care plan last revised on 12/21/23 indicated Resident #1 was at risk for falls related to
multiple previous falls. There was an intervention for a fall mat while in bed.
Record review of a video dated 12/19/23 at 10:00 p.m., revealed Resident #1 was in bed. She fell out of the
bed onto the floor. There was not a fall mat beside the bed .
Record review of a Progress Note dated 12/19/23 at 11:36 p.m. indicated, upon entering room resident onb
floor next to be on lt (left) side, wrapped in blanket which helped cusion resident. 2cm (centimeter) X 3 cm
s/t (skin tear) noted to lt (left) elbow, cleaned and steri/stripps applied as well as non-stick dressing. Neuro
vs (vital signs) wnl (within normal limits). Placed in bed and call light in easy reach, bed in low position.
Message left on (responsible party's) phone .
Record review of a Progress Note dated 12/20/23 at 9:26 a.m. indicated, knot and bruise observed on tope
left side of scalp r/t (related to) fall, rsd (resident) denies pain, VS (vital signs) stable) at last neuro check
.hospice nurse .stated no new orders at this time.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675553
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675553
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quitman Wellness & Rehabilitation
1026 E Goode St
Quitman, TX 75783
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Record review of a staff Assignment Sheet dated 12/19/23 indicated the staff for the 6 p.m. to 6 a.m. shift
were LVN A, CNA B, and CNA C.
On 12/28/23 at 11:30 a.m., a call was attempted to LVN A. There was no answer. The mailbox was full. A
detailed text message was sent requesting a return call.
Residents Affected - Few
On 12/28/23 at 12:59 p.m., a second call was attempted to LVN A. There was no answer. The mailbox was
full. A detailed text message was sent requesting a return call. No call was received prior to exit.
On 12/28/23 at 1:38 p.m., a call was attempted to CNA B. There was no answer. The call went straight to
voicemail. A detailed message was left, requesting a return call.
On 12/28/23 at 1:40 p.m., a call was attempted to CNA C. The call went straight to voicemail. The voicemail
box was full.
On 1/02/24 at 10:46 a.m., a call was attempted to CNA B. There was no answer. The call went straight to
voicemail. A detailed message was left, requesting a return call. No return call was received prior to exit.
On 01/02/24 at 10:47 a.m., a call was attempted to CNA C. The call went straight to voicemail. The
voicemail box was full. No return call was received prior to exit.
During an interview on 01/02/24 at 11:06 a.m., the Administrator said he had reached out to CNA B and
CNA C and was unable to reach them. He said they had worked the previous night shift and he would
continue to reach out to them.
During an interview on 01/02/24 at 11:25 a.m., the DON said she would have expected for the care plan to
have been followed by staff. She said she would have expected for there to have been a fall mat beside the
bed of Resident #1 when she fell. She said not having a fall mat or other fall interventions to have not been
implemented appropriately could lead to injury .
During an interview on 01/02/24 at 11:45 a.m., the Administrator said he would have expected for there to
have been a fall mat beside the bed of Resident #1 when she fell out of bed. He said fall preventions not
being in place could cause fall injuries to be more significant.
Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 indicated,
.A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet
the resident's physical, psychosocial and functional needs is developed and implemented for each resident
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675553
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675553
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quitman Wellness & Rehabilitation
1026 E Goode St
Quitman, TX 75783
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to in accordance with accepted professional standards and
practices, maintain medical records on each resident that was accurately documented for 1 of 5 residents
(Resident #1) reviewed for accuracy of medical records.
The facility failed to ensure LVN A did not falsify Neurological Assessments for Resident #1.
This failure could place residents at risk for inaccurate assessments and monitoring.
Findings include:
Record review of a face sheet dated 12/28/23 revealed Resident #1 was [AGE] years old and was admitted
on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), heart
failure, and anxiety.
Record review of the most recent MDS dated [DATE] indicated Resident #1 had a BIMS score of 10 which
indicated moderate cognitive impairment. The MDS indicated Resident #1 was dependent on staff for
assistance with ADLs.
Record review of a care plan last revised on 12/21/23 indicated Resident #1 was at risk for falls related to
multiple previous falls and had actual falls. There was an intervention to, Monitor for changes in condition,
document and report to MD/NP; localized swelling, c/o (complaints of) pain, increased lethargy, abnormal
neuro vital signs .
Record review of Neurological assessment dated [DATE] - 12/20/23 indicated LVN A completed
neurological assessments on Resident #1 on 12/19/23 at 10:30 p.m., 10:45 p.m., 11:00 p.m., 11:15 p.m.,
11:45 p.m. and on 12/20/23 at 12:15 a.m., 1:15 a.m., 2:15 a.m., 3:15 a.m., 04:15 a.m. and 05:15 a.m.
Record review of a Progress Note dated 12/19/23 at 11:36 p.m. indicated, upon entering room resident onb
floor next to be on lt (left) side, wrapped in blanket which helped cusion resident. 2cm (centimeter) X 3 cm
s/t (skin tear) noted to lt (left) elbow, cleaned and steri/stripps applied as well as non-stick dressing. Neuro
vs (vital signs) wnl (within normal limits). Placed in bed and call light in easy reach, bed in low position.
Message left on (responsible party's) phone .
Record review of a Progress Note dated 12/20/23 at 9:26 a.m. indicated, knot and bruise observed on tope
left side of scalp r/t (related to) fall, rsd (resident) denies pain, VS (vital signs) stable) at last neuro check
.hospice nurse .stated no new orders at this time.
Record review of a video dated 12/19/23 at 10:00 p.m., revealed Resident #1 was in bed. She fell out of the
bed onto the floor. There was not a fall mat beside the bed. The resident said to staff that she hit her head.
Record review of a Provider Investigation Report dated 12/28/23 and concerning Resident #1 indicated,
.staff was witnessed on camera in resident room to not perform neuro checks periodically after resident had
an unwitnessed fall in her room. Resident assessment was performed after the fall with family alleging that
the nurse did not continue to monitor her condition over time . The nurse was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675553
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675553
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Quitman Wellness & Rehabilitation
1026 E Goode St
Quitman, TX 75783
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
identified as LVN A. The LVN was suspended immediately pending investigation. The report indicated the
resident fell on [DATE]. The report indicated, .The nurse in question wrote a statement confirming that the
nurse did not perform neuro evaluations correctly . The investigation findings were confirmed. The report
indicated, .Nurse was terminated after conclusion of investigation for failure to document neuro checks as
required .
Residents Affected - Few
Record review of an undated handwritten statement signed by LVN A indicated, Called to room by CNA's.
Resident on floor next to bed wrapped in blanket .I did fill out a neuro VS. (vital sign) sheet at end of shift,
but did not turn it in. The break in protocol was not doing neuro VS. I just did not have the time .I apologize
for the break in protocol.
On 12/28/23 at 11:30 a.m., a call was attempted to LVN A. There was no answer. The mailbox was full. A
detailed text message was sent requesting a return call.
On 12/28/23 at 12:59 p.m., a second was call attempted to LVN A. There was no answer. The mailbox was
full. A detailed text message was sent requesting a return call. No call was received prior to exit.
During an interview on 01/02/24 at 11:25 a.m., the DON said she would have expected for LVN A to have
completed neurological checks per protocol for Resident #1. She said LVN A did admit that he falsified the
neurological assessments he did chart. She said falsifying documentation could lead to a change in
condition not being noticed. She said the Neurological Assessment sheet filled in by LVN A was left on a
clipboard at the nurse's station .
During an interview on 01/02/04 at 11:45 a.m., the Administrator said LVN A did admit to falsifying the
neuro assessment documentation. He said he would have expected LVN A to have completed neuro
checks on Resident #1 and to have accurately documented them. He said LVN A said he did do the first set
of neurological checks, but he made up the rest of the documentation. He said after LVN A confessed to
falsifying the documentation, he was terminated immediately for resident safety. He said a nurse falsifying
documentation he would be afraid something clinically might not be recognized. He said there could be an
adverse reaction.
Review of an Assessing Falls and Their Causes facility policy dated April 2022 indicated, .if a resident has
just fallen or is observed on the floor without a witness to the even, evaluate for possible injury to the head
.observe for delayed complications of a fall .and will document findings in the medical record .
Review of a Charting and Documentation facility policy dated July 2017 indicated, .Documentation in the
medical record will be objective (not opinionated or speculative), complete, and accurate .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675553
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 2, 2024 survey of Quitman Wellness & Rehabilitation?
This was a inspection survey of Quitman Wellness & Rehabilitation on January 2, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Quitman Wellness & Rehabilitation on January 2, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.