Concho Health & Rehabilitation Center

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for accuracy and completeness. Facility failed to document that Resident #1 wound care was completed on 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. This deficient practice could put residents at risk of not receiving needed services although services are documented as having been provided. Record review of Resident #1's detailed summary report/face sheet dated 12.18.25 indicated he was admitted to facility on 11.17.25 with diagnoses of heart failure, anemia, and type 2 diabetes. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #1) reviewed for Abuse. The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #1 alleged abuse occurred during a recent hospital visit. This deficient practice could delay assessment and care of residents who report abuse.

Inspectors wroteBased on observation, 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, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described services that attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. : The facility failed to ensure a Care Plan was developed to address Resident #2's dry skin (skin was not falling off the body the way it should). This failure could place residents at risk of not receiving individualized care and services to meet their needs.

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 (Resident #7) of two residents reviewed for infection control practices. LVN A failed to sanitize the glucometer with a germicidal wipe after she performed a blood sugar check on Resident #7. This failure could affect the residents by placing them at risk for the spread of infection.

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 in the facility's only kitchen in that: The facility failed to ensure kitchen staff wore facial hair restraints during meal preparation. These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination.

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 to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #5, #9 and #31) of 5 residents reviewed for infection control. The facility failed to ensure: CNA E did not turn off the faucet with her bare hands after washing them and before performing personal care for Resident #5. CNA's E and F change their gloves after they became contaminated during incontinent care while assisting Resident #9. CNA B change her gloves after they became contaminated during incontinent care while assisting Resident #31. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident hazards/supervision (Resident #5). The facility failed to ensure CNA E and G demonstrated appropriate transfer techniques while using the mechanical lift for Resident #5. These failures could place residents at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 2 medication carts (Med Cart #1), reviewed for labeling/storage of drugs and biologicals. The facility failed to secure controlled medication in a locked compartment. These failures could place the facility at risk of drug diversion and access to medications.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 10 residents (Resident #44, Resident # 148) reviewed for resident rights . The facility failed to obtain informed consent from Resident #44 prior to administering Bupropion, an antidepressant used to treat depression. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that: Resident #5 did not have a care plan to address her pain. Resident #20 did not have a care plan to address her pain. Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 10 of 41 residents (Residents #6, #10, #11, #13, #14, #17, #18, #25, #28, #32) reviewed for safe, functional equipment, in that: Residents #6, #10, #11, #13, #14, #17, #18, #25, #28 and #32 wheelchairs, to include the brakes, were not in safe working order. These failures could place residents at risk for skin issues, discomfort, and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). CNA A failed to complete an appropriate one-person gait belt transfer. This failure could place residents at risk of inadequate supervision and preventable injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for 1 of 3 medication carts and 1 of 1 surplus-stocked medication cart reviewed for medication storage. Medication Cart #1 had seven (7) expired medications. Medication Surplus Cart had one (1) expired controlled medication of ten (10) capsules in the med storage room, available for use. This failure could place residents at risk for not receiving the therapeutic effects of the medications ordered.