Health inspection·June 11, 2024

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall): Residents Affected - Few 1)Roaches were observed crawling on the walls and floor in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall), and 2) The pest control program was further compromised due to the facility having harborage areas that were not repaired, clean and/or orderly (hand sink cabinetry and adjacent wall area, clutter). These failures could place residents at risk for infections. The findings include: During confidential resident interviews, 4 of 6 residents stated they had observed roach activity in the facility. One resident stated, I've seen them in the bathroom, closet and bed area. I've seen new hatchlings. He further stated housekeeping in his room varies and could go three or four days without housekeeping coming to his room. He stated, They don't clean under the bed. Another resident stated, They (Pest Control Vendor) sprayed not too long ago. He stated he last saw a roach in the facility approximately a month ago. One other resident stated, I have seen a few. The last I've seen was the first of the month in the room crawling on the floor. Another resident stated he had last seen roaches approximately four months ago and that was when his roommate had food in the room. Observation on 6/11/24 at 3:22 PM in room [ROOM NUMBER] (occupied) there was an adult roach crawling on the wall under the hand sink in an area that had a gap near the wall water inlet. The area had a heavy accumulation of specs/roach feces . There were gaps in the hand sink cabinetry where there was specs built up. One small pre-adult/nymph roach fell from the underside of the hand sink cabinet onto the floor and crawled away. There was another large adult roach crawling in one of the gaps between the hand sink cabinetry frame. The roaches were also observed by the Maintenance Supervisor. The room had cluttered areas, and there were 3 extra mattresses stacked on the vacant A bed. The privacy curtains were drawn around the vacant bed and the room was dark. On 6/11/24 at 3:30 PM an interview was conducted with the Maintenance Supervisor. He stated that the facility had been sprayed twice in the last month. He added the Pest Control Vendor came last month (May 2024) for roaches. He stated there were bedbugs in room [ROOM NUMBER] and the Pest Control Vendor found no others in the facility; that was approximately two or three weeks ago. He stated, roaches could get out of control, and the facility could get infested. He further stated roaches could (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 3 Event ID: 675853 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 675853 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hansford County Hospital District Dba Lakeridge Nu 4403 74th St Lubbock, TX 79424 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)