Capstone Healthcare of Perryton

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #33) of 12 residents reviewed for resident rights. The facility failed to ensure Resident #33's naked bottom was not visible to other residents in the common area as he was wheeled into the facility on [DATE]. This failure could place residents at risk of embarrassment, feelings of insecurity, and/or diminished self-esteem. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 1 (Resident #5) of 12 residents reviewed for assessments. The facility failed to complete Resident #5's significant change MDS within 14 days of her admission to hospice care on 06/10/26. This failure could place residents at risk of not receiving necessary care/coordination of care. Findings Included:Record review of Resident #5's admission record dated 06/24/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her Primary Payer was noted to be Hospice. Record review of Resident #5's EHR under the MDS tab revealed no significant change MDS assessment in the last year. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #28) of 12 residents reviewed for accuracy of assessment. The facility failed to ensure Resident #28's admission MDS indicated his use of tobacco. This failure could place residents at risk of not receiving necessary care/supervision. Findings Included:Record review of Resident #28's admission record dated 06/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #28's quarterly MDS completed on 03/19/26 revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #28's admission MDS with an ARD of 07/29/25 revealed it was completed on 07/30/25. Section J Health Conditions revealed Resident #28 did not use tobacco. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of misappropriation immediately, but not later than 24 hours after the allegation is made, if the events that cause the allegation did not involve abuse or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 1 of 1 facilities reviewed for misappropriation. The facility failed to report to the State Survey Agency when money went missing from a Resident's room. This could place at risk of missing property being reported to the State Agency.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure each resident had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard, and the right to promptly receive unopened mail and other letters and the privacy of such communication for 4 of 4 residents (Resident #s 3, 4, 7 and 11) reviewed for resident rights. The facility failed to ensure that Residents #3, #4, #7 and #11 had access to a telephone where personal calls could be made without being overheard. The facility failed to ensure that Residents #3, #4, #7 and #11 promptly received unopened mail and other letters. These failures could place residents at risk of frustration, a reduced confidence in administration and a decrease in resident rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from bedrails and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 7 (Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119) of 14 residents reviewed for bed rails. The facility failed to assess Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119 for risk of entrapment prior to installing bed rails. The facility failed to obtain informed consent for bed rails from Resident #10, Resident #11, Resident #13, Resident #15, Resident #16, Resident #69, and Resident #119 or their resident representatives prior to installing bed rails. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen(s) reviewed for food safety. The facility failed to ensure all foods in the freezer were properly sealed, labeled and dated. The facility failed to ensure all foods in the refrigerator were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were properly sealed, labeled and dated. These failures could place residents at risk of food-borne illness, diminished nutritional value and a reduced quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assess residents in a way that accurately reflected the resident's functional status for 2 of 14 residents (Resident # 5 and Resident #15) reviewed for accuracy of assessment. The facility failed to assess Resident #5 and Resident #15's ability to feed themselves with only set up help provided by facility staff. This failure could place residents at risk of a reduced level of daily caloric intake, a decline in overall health and well-being and an undesired decrease in weight.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 14 residents reviewed for respiratory care. The facility failed to ensure Resident #1 received O2 via NC at the rate of 4 lpm as ordered by her physician. This failure could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (the treatment cart) of 2 medication carts (1 treatment cart and 1 medication cart) and 1 of 17 resident rooms reviewed for medication safety. The treatment cart contained two insulins that were opened and accessed that were not marked with the expiration date. Resident #69's room contained two medications (Fluticasone Propionate Nasal Suspension and Systane Eyedrops) that should have been stored in locked compartments. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #119) of 14 residents reviewed for medical records. The facility failed to ensure the DON did not back date a consent for bedrails for Resident #119. This failure could place residents at risk of receiving inaccurate care/treatment due to inaccurate records. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (RN B) of 4 staff observed for infection control. -RN B did not wash her hands after changing her gloves when performing wound care for Resident #15. This deficient practice has the potential to affect residents in the facility receiving wound care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #3, #5 and #10) of 16 residents reviewed for advanced directives. Residents #3, #5, and #10 had DNR's in their records that were missing required information including dates and signatures. These failures placed residents at risk of not having their end of life wishes honored which could result in prolonged pain and suffering and physical harms in the event of CPR being administered against a resident's wishes.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident receives adequate supervision for 3 of 16 residents (Resident #7, Resident #9 and Resident #10) reviewed for accidents and hazards. Smoking materials were left out unsupervised. Residents #7, #9, and #10 were smoking outside without supervision. This failure could result in physical and mental harm. Findings Include: Record review of Resident #7's face sheet, dated 3/4/24, showed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed. Dry goods were not stored in sealed containers. Refrigerated and frozen food were not labeled or stored correctly. This failure can result in cross contamination, bacteria, pests, and harm to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 12 residents (Resident #7) reviewed for accuracy of MDS assessments. -The facility did not correctly identify tobacco use for Resident #7 on his annual MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights set forth with goals for admission and desired outcomes for 1 of 16 residents (Resident #5) reviewed for care plans. Resident #5 care plan focus areas of DNR, diagnoses of hypertension, physical mobility, cognitive functioning, antidepressant medication, and psychotropic medication had minimal or no person centered goals or interventions to meet the resident's specific needs. This failure can result in inadequate/incorrect care or harm.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of a comprehensive assessment for 1 (Resident #15) of 12 residents reviewed for comprehensive care plans. The facility failed to develop Resident #15's comprehensive care plan within 7 days after completing her admission MDS assessment. The deficient practice could affect residents by delaying treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure that residents unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 16 residents (Resident #5) reviewed for choices. Resident #5 was told no when asking staff to shave her legs during her showers. This failure can result in residents not receiving proper care and not attaining their highest level of physical, mental, and psychosocial well-being. Findings Include: Record review of Resident #5's face sheet, dated 3/5/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one facility reviewed for infection control, in that: Staff were not masking as required by the facility during a COVID outbreak. Staff were doffing used PPE and placing it on furniture in the rooms of COVID positive residents. These failures could place residents at risk of contracting infectious diseases. Findings Included: [...]