F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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 Registered Nurse (RN) for
at least 8 consecutive hours a day, 7 days a week for 4 of 4 months reviewed. (January 2023, February
2023, March 2023, and June 2023)
The facility did not have the required 8 consecutive hours of RN coverage during the months of January
2023 (4 days), February 2023 (2 days), March 2023 (2 days), and June 2023 (3 days).
This failure could place residents at risk for not having their nursing care and medical needs met.
Findings include:
Record review of the January 2023 time sheets indicated no RN worked on Monday 01/02/23, Sunday
01/15/23, Monday 01/16/23 and Tuesday 01/17/2023.
Record review of the February 2023 time sheets indicated no RN worked on Saturday 02/04/2023 and
Sunday 02/19/2023.
Record review of the March 2023 time sheets indicated no RN worked on Tuesday 03/14/2023 and
Saturday 03/25/2023.
Record review of the June 2023 time sheets indicated no RN worked on Saturday 06/10/2023, Sunday
06/11/2023, and Saturday 06/24/2023.
During an interview on 06/28/2023 at 10:30 AM with the DON, she said she tried to cover any days that she
did not have an RN charge nurse.
During an interview on 06/28/2023 at 10:40 AM with the BOM, she said she reviewed the time sheets of the
DON for the months of January, February, March, and June of 2023 and said the DON did not work on any
of the days in question.
During an interview on 06/28/2023 at 11:30 AM with the ADON, she said the DON made the nursing
schedule. She said the facility has a daily nursing stand-up meeting but have not been reviewing RN
nursing coverage needs during that meeting.
During an interview on 06/28/2023 at 11:40 AM with the ADM, said the facility has a scheduler, which was
the DON, to ensure RN coverage requirements were met and a system where staff can pick up open
(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:
676072
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
676072
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Corrigan Ltc Nursing & Rehabilitation
300 Hyde St
Corrigan, TX 75939
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 0727
shifts.
Level of Harm - Minimal harm
or potential for actual harm
A review of the facility's undated policy titled Staffing indicated the facility has an RN available for coverage
8 hours a day, 7 days a week.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676072
If continuation sheet
Page 2 of 3
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
676072
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Corrigan Ltc Nursing & Rehabilitation
300 Hyde St
Corrigan, TX 75939
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure that the facility's Medical Director
attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement
Committee meetings, for 2 of 2 quarterly meetings (April, May, June 2022 and July, August, September
2022), reviewed for QAA/QAPI.
Residents Affected - Some
The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of
April 2022 through September 2022.
This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans
of actions developed or implemented, and no appropriate guidance developed.
Findings included:
Review of the facility's QAA/QAPI meeting signature logs for the months of April 2022 through September
2022, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee,
during those months. There were no notation indicating the Medical Director had attended any of the
meetings by telephone or zoom.
During an interview on 06/28/2023 at 1:35 PM, the Administrator said the QAA/QAIP met monthly, but no
less than once per quarter. She said she realized the Medical Director was not in attendance for the
QAA/QAIP meetings for the months of April 2022 through September 2022, but she could not say why he
was not in attendance. She said she was not the Administrator at that time, she became the Administrator
in February 2023 and could not speak to anything prior to that. She said there was no indication the
Medical Director had attended any of the meetings between April 2022 and September 2022, by telephone
or zoom.
Review of the facility's Quality Assurance and Performance Improvement (QAPI Program - Governance
Leadership (revised March 2020) revealed, Policy Statement: This facility shall develop, implement, and
maintain an ongoing, facility-wide, data driven QAPI Plan that is focused on indicators of the outcomes of
care and quality of life for our residents. Governance and Leadership: 1. The Administrator, weather a
member of the QAPI Committee or not, is ultimately responsible for the QAPI Program . 6. The following
individuals serve on the committee: Administrator, DON, Medical Director, Infection Preventionist and
representative from various departments . 7. The committee meets at least quarterly .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676072
If continuation sheet
Page 3 of 3
