Health inspection·August 10, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage (January 2023, February 2023, and March 2023). The facility did not have the required 8 consecutive hours of RN coverage during the months of January 2023 (4 days), February 2023 (3 days), and March 2023 (1 days). This failure could place residents at risk for not having their nursing care and medical needs met. Findings included: Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 08/04/2023 revealed No RN Hours was triggered for the fiscal year Quarter 2 2023 (January 1 - March 31). The infraction dates were 01/08 (SU); 01/15 (SU); 01/21 (SA); 01/22 (SU); 02/04 (SA); 02/05 (SU); 02/12 (SU); 03/11 (SA); 03/18 (SA). Record review of the January 2023 time sheets indicated no RN worked on Sunday 01/08/23, Sunday 01/15/2023, Saturday 01/21/2023, and Sunday 01/22/2023. Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023, Sunday 02/05/2023, and Sunday 02/12/2023. Record review of the March 2023 time sheets indicated no RN worked on Saturday 03/11/2023. In an interview on 8/10/23 at 1:50 PM, the ADON stated that the facility had requested agency RN coverage for all the days listed on the PBJ report. She stated that the days listed on the report were all due to last minute call ins and because they were such a rural facility, getting someone to cover the shifts was very difficult. The ADON stated that the facility used multiple staffing agencies from surrounding cities, and they were not able to get anyone last minute for those shifts. She stated the facility did not have a policy to address the time frame for calling in, and that employees were instructed to call in in a timely manner so that management could try to cover the shift. The ADON stated that the facility had four RNs on staff and was using agency RNs for weekend coverage to avoid having any gaps in coverage like what they experienced in January, February, and March. She stated there have been no staffing issues since March 2023. In an interview on 8/10/23 at 2:15 PM, the DON stated that on the dates listed on the PBJ report (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: 676020 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 676020 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menard Manor 100 Gay St Menard, TX 76859 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)