Focused Care at Lamesa

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 3 (Resident #44, Resident #1 and Resident #22) of 4 residents reviewed for infection control. CNA C failed to sanitize hands between glove changes during incontinent care on 07/27/26 for Resident #44. LVN A failed to wear proper PPE (a gown) when providing wound care on 07/27/26 for Resident #1 who was on EBP and while assisting LVN B with wound care on 07/27/26 for Resident #22 who was on EBP. LVN B failed to wear proper PPE (a gown) when assisting LVN A with wound care on 07/27/26 for Resident #1 who was on EBP. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 51). The facility failed to ensure Resident #51 wore a smoking apron as indicated in his physician orders during the smoke break on 07/27/26 at 11AM. This failure could place residents at risk for inadequate protection from potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 (Resident #58) of 6 residents reviewed for respiratory care. The facility failed to ensure that Resident #58's oxygen tubing was stored properly while not in use when it was observed on the floor during an initial tour observation on 07/26/26 and on an observation on 07/27/26. This failure could place residents at risk for respiratory compromise and infection. Record review of Resident #58's admission Record dated 07/28/26 reflected a [AGE] year-old female with an original admission date of 07/22/17. Resident #58 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 5 medication carts (Overstock Medication Cart and Treatment Cart) observed for storage. The facility failed to ensure the Overstock Medication Cart and Treatment Cart were secured when unattended on 7/26/26. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.

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 1 of 1 kitchen (Kitchen A) reviewed for food storage. On 07/26/2026 facility failed to properly label food stored in the refrigerator. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased 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, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 5 residents reviewed for care plans. The facility failed to develop a care plan for use of a Wander Guard electronic signaling device, utilized for wander-management, for Resident #1. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Record review of the admission record for Resident #1, dated 04/14/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menus were followed for 1 of 1 meal (lunch meal) on 01/07/2026 reviewed for meal accuracy, in that: DM B failed to serve the correct portion size of spaghetti noodles, marinara sauce and tossed salad according to the prepared menu for lunch for 50 residents. Dietary Aide C failed to follow the recipe for meat marinara sauce, causing them to run out of meat marinara sauce before they finished serving the lunch meal on 01/07/2026, and 9 residents did not receive meat marinara sauce. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 16 of 21 confidential residents. The facility failed to ensure 16 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, access to Grievance forms, information regarding who the facility Grievance officer was with their contact information, and accommodations to file an anonymous Grievance. This failure could place the residents at risk of unresolved Grievances and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 16 residents (Resident #40) reviewed for advance directives. The facility failed to ensure Resident #40's Out of Hospital Do Not Resuscitate (OOHR) form was signed and dated by the resident's physician and included the physician's license number. The facility failed to ensure Resident #40's OOH DNR contained accurate dates from Resident #40's Legal Guardian and the two witnesses. This failure could place residents at risk for not having their end of life wishes honored and having incomplete records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #36) reviewed for supervision, 1. The facility failed to provide effective monitoring and interventions to reduce Resident #36's wandering which was intrusive to other residents' privacy and unsafe for Resident #36 and other residents 2. The facility failed to keep the administrative offices closed and not accessible to the residents when no staff were present. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals.

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 1 of 6 residents (Residents #39) reviewed for infection control. 1. CNA A failed to change her gloves and utilize hand hygiene during incontinence care with Resident #39. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 31 of 31 residents reviewed for infection control (Residents #1- #31). 1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination from residents (Resident #3, #4, #6, and #28) positive with COVID-19. 2. The facility failed to place readily visible signage on the door of Resident #1-#30 who was actively on contact precautions. 3. The DM and CNA A entered the room of a resident (Resident #6 and #28) who was on transmission-based precautions without proper PPE. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 2 of 17 residents (Residents #23, and #47) reviewed for transfers, in that: The facility did not provide Resident #23 and Resident #47 with a written bed-hold policy when the residents were transferred out to the hospital or were on therapeutic leave. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions.

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 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. The facility failed to protect foods from potential contamination. Foods were not handled in a manner to prevent contamination. Food contact equipment and other equipment was not maintained in a clean manner. Foods were not stored according to manufacturer's recommendation. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation , interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. The facility failed to ensure that the kitchen oven was maintained in safe operating condition. The facility failed to ensure that the kitchen coffee machine was maintained in safe operating condition. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies.

Inspectors wroteBased on record review, observations and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 7 of 17 residents (Residents #12, #14, #23, #28, #40, #44 and #47) reviewed for care plans as follows: Resident #12 did not have a care plan for urinary incontinence. Resident #14 did not have a care plan for urinary incontinence. Resident #23 did not have a care plan for urinary incontinence. Resident #28 did not have a care plan for urinary and dehydration. Resident #40 did not have a care plan for cognitive loss, vision, communication, urinary incontinence, and dental care. Resident #44 did not have a care plan for falls. Resident #47 did not have a care plan for cognitive loss. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 4 of 6 (Residents #1, #31, #38 and #45) and 2 of 2 (CNA C and CNA D) and 1 of 1 (LVN A) staff reviewed for infection control. 1. CNA C failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #45. 2. CNA D failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #1. 3. LVN A failed to clean surface before placing wound supplies on surface while providing wound care to Resident #31 and Resident #38. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 1 treatment cart observed for drug storage. The facility failed to ensure LVN B did not leave wound cleanser on top of the treatment cart unsupervised. This failure could place residents at risk of harm due to misuse or accidental ingestion. ,.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion for 1 of 5 residents (Resident #1) reviewed for abuse in that: The AP made Resident #1 clean up his own excrement from the floor and the toilet on 11/13/23. The AP threatened Resident #1 that if he did not clean up his excrement, he would not be able to go and smoke during the evening smoke break. LVN B failed to follow up and ensure that Resident #1 was free from abuse after the AP verbalize that she was going to make Resident #1 clean up his own excrement. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, 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 (Resident #1) reviewed for abuse and neglect. The DON failed to respond to LVN A's report of the AP verbalizing that she would make Resident #1 clean up his own excrement from the toilet and the floor as a result no investigation was initiated. [...]