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 for each resident, consistent with the resident rights, which included measurable objectives and
timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified
in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility
failed to develop and implement Resident #1's care plan for behavior towards other residents after he hit
Resident #2 with a fly swatter on 11/18/25. This failure could place residents at risk of further incidents of
aggression. Findings included: Record review of Resident #1's face sheet dated 01/07/25 indicated he was
a [AGE] year old male admitted on [DATE] and his diagnoses included hemiplegia (severe paralysis) and
hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left dominant side,
intermittent explosive disorder (mental health condition characterized by sudden, impulsive outbursts of
anger or violence that are disproportionate to the triggering situation), personality change due to known
physiological condition, and anxiety disorder (persistent excessive worry). Record review of Resident #1's
significant change MDS dated [DATE] indicated he was usually able to make himself understood and
usually understood others. He was cognitive (BIMS-15). There was no aggressive behaviors noted. Record
review of Resident #1's care plan dated 05/23/24 indicated he was aggressive and argumentative with staff.
Interventions included administer medications as ordered, intervene as necessary to protect the rights and
safety of others, and referred to counselling services. There was no review or update noted related to
Resident #1 hitting Resident #2 with the fly swatter on 11/18/25. Record review of Resident #2's face sheet
dated 01/06/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included
Parkinson's (neurodegenerative disease), anxiety (persistent excessive worry), and schizoaffective
disorder-bipolar type (mental health condition characterized by symptoms of both schizophrenia and mood
disorders, particularly mania and depression). Record review of Resident #2's significant change MDS
dated [DATE] indicated he was usually able to make self understood, was able to understand others, had
moderate cognitive impairment (BIMS-9), had an acute change in mental status with fluctuating inattention
and disorganized thinking. There was no aggressive behaviors noted. Record review of Resident #2's care
plan dated 09/05/25 indicated he had a behavior problem related to bipolar disorder. Interventions included
weekly counseling services. Record review of an incident report dated 11/18/25 at 4:28 p.m., completed by
LVN C indicated Resident #1 was in the dining room and hit another resident (Resident #2) with a fly
swatter. When asked what happened, Resident #1 stated He wanted to call me his kid brother and I wanted
to aggravate him so I hit him with the fly swatter. Resident #1 was taken to his room to diffuse the situation
and was placed on 1-1. Administrator notified of physical aggression. Physician and psychiatric services
notified. Received order to send Resident #1 to behavioral hospital. Record review of the facility
investigation dated 11/24/25 indicated
(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
01/06/2026
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Resident #1 hit Resident #2 with a fly swatter on 11/18/25 at 4:30 p.m. Resident #1 and Resident #2 were
separated and assessed. There were no injuries. Resident #1 was placed on 1 to 1 supervision. Resident
#1 was transferred to a behavioral hospital on [DATE]. The facility confirmed resident to resident altercation.
Record review of Resident #1's behavioral hospital records dated 12/03/25 indicated the reason for his
admission included hitting another resident with a fly swatter and intentionally aggravating the other
resident. During an interview on 01/05/26 at 1:42 p.m. Resident #2 said Resident #1 hit him to bug (bother)
him with a fly swatter because he said Resident #1 could be a little brother. He said he was not hurt. He
said he was not afraid and he was friends with Resident #1. During an interview on 01/05/26 at 1:50 p.m.,
Resident #1 said he hit Resident #2 with a fly swatter because he wanted to irritate him after Resident #2
said he (Resident #1) should be his little brother. He said he was not trying to hurt Resident #2, he was only
trying to irritate him. During an interview on 01/05/26 at 3:23 p.m., the Administrator said there was no
history of Resident #1 showing aggression towards other residents. She said when Resident #1 was
readmitted from the behavioral hospital on [DATE]. She said the incident and care plan was reviewed on
12/04/25 and changes were supposed to be made but it was not saved in the electronic record. She said
the incident that occurred on 11/18/25 was also supposed to be added to the care plan on 11/20/25
however it did not update and save in the electronic record. She said if care plans were not reviewed and
updated the risks included staff not being aware of appropriate interventions for behavior management.
During an interview on 01/05/26 at 3:28 p.m., the DON said Resident #1 was supposed to attend outpatient
services provided by the behavior hospital however he refused to go after 1 or 2 appointments. She said
the care plan was not updated as required. She said the previous DON was supposed to review and update
the care plan as required. During an interview on 01/06/26 at 10:30 a.m., LVN C said she did not witness
the incident between Resident #1 and Resident #2. She said Resident #1 did not have a history of
aggression toward other residents. She said Resident #1 said he wanted to aggravate Resident #2 to see
what he would do. She said Resident #1 was placed on 1-1 immediately after the incident until he was
transferred to a behavior hospital. During an interview on 01/06/26 at 10:55 a.m. the DON said a CNA told
her of the incident on 11/18/25 but she could not recall which CNA. She said she went to the dining room
and Resident #1 was still holding the fly swatter. She said Resident #1 was no longer near Resident #2.
She said he was still holding the fly swatter. She said Resident #1 was placed on 1-1 and remained in his
room until he was transported to the behavior hospital on [DATE]. She said the fly swatter was removed
from Resident #1's possession and disposed. During an interview on 01/06/26 at 11:14 a.m., Resident #3
said he witnessed Resident #1 hit Resident #2 with a fly swatter. He said Resident #1 was trying to irritate
Resident #2. He said Resident #2 was upset with Resident #1 and moved to another table. He said he
never saw Resident #1 hit Resident #2 or any other resident before. Record review of a text message sent
to the Administrator by the previous DON on 01/06/26 indicated she did not recall anything of the incident
on 11/18/25 other than she sat 1-1 with Resident #1 until he went to the behavior hospital on [DATE]. The
surveyor attempted to contact CNA A regarding Resident #1 hitting Resident #2 with the fly swatter on
01/06/26 at 11:05 a.m. by phone. A voice message was sent with the surveyor's contact information. As of
the investigation exit, CNA A did not respond. The surveyor attempted to contact CNA B regarding Resident
#1 hitting Resident #2 with the fly swatter on 01/06/26 at 11:08 a.m. by phone. CNA B's phone was not
accepting calls. A text message was sent with the surveyor's contact information. As of the investigation
exit, CNA B did not respond. Record review of the facility's policy Resident-to-Resident Altercations dated
2001 (revised 09/2022) indicated .4. If two residents are involved in an altercation, staff .f. make necessary
(continued on next page)
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
01/06/2026
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 0656
Level of Harm - Minimal harm
or potential for actual harm
changed in the care plan approaches to any or all of the involved individuals; g. document in the resident's
clinical record all interventions and their effectiveness; h. consult psychiatric services as needed for
assistance in assessing the resident, identifying causes, and developing a care plan for intervention and
management as necessary or as may be recommended by the attending physician or interdisciplinary care
planning team; .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676072
If continuation sheet
Page 3 of 3