Nocona Rehabilitation and Care Center

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 one of one kitchen, in that: The facility failed to store nonperishable dry foods in the kitchen that were sealed and/or labeled with open date. The facility failed to store foods in the refrigerator that were labeled with an identifier and/or open date. The facility failed to discard expired or spoiled foods. These failures could place residents at risk for decline in nutritional health status and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to Center for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 Fiscal Year (FY) quarters reviewed. FY Quarter 4 2025 (July 1 - September 30) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 4 2025 (July 1 - September 30). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility's reviewed for QAPI. The facility failed to maintain documentation of QAPI meetings prior to November of 2025. This failure placed residents at risk of maintaining and improving safety and quality of life.

Inspectors wroteBased on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing Antibiotic Stewardship program for 1 of 1 facility's reviewed for Antibiotic Stewardship. The facility failed to provide documentation of appropriate monitoring of antibiotic use for residents by not providing the track and trending log prior to November 2025. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of training requirements for 7 of 16 (DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H) employees reviewed for training. The facility failed to maintain evidence that the DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H were trained for infection control. The facility failed to maintain evidence that RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H were trained for compliance and ethics. The facility failed to maintain evidence that RN C, RN D, CNA F, and Laundry G were trained for Resident Rights. The facility failed to maintain evidence that RN C, LVN E, CNA F, Laundry G, and Housekeeping H were trained for QAPI.The facility failed to maintain evidence that RN C, CNA F, and Laundry G were trained for abuse and neglect. [...]

Inspectors wroteBased on interview and record review the facility failed to implement a grievance policy that included the maintenance of documentation of all grievances for no less than 3 years from the issuance of the grievance decision. The facility failed to have documentation and evidence of grievances filed for the previous 3 years. This failure could place the residents at risk for a decreased quality of life and care within their living environment, and/or not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to act upon the consultant pharmacist's medication regimen review report to the attending physician for 1 of 5 residents (Resident #7) reviewed for unnecessary medications. Resident #7's attending physician wrote an order dated 1/11/2026 for a dose reduction in the antipsychotic medication Seroquel 50 mg at HS to Seroquel 25 mg at HS per the Consultant Pharmacist's recommendation dated 11/23/2025. The order was not noted by the facility's licensed nursing staff and the order was not changed. This failure placed the resident at risk for adverse effects from continued medication administration at a dose that was not reduced as ordered by the physician.

Inspectors wroteBased on record review and interviews, 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 13 of 104 days for months (July 2025, August 2025, September 2025 and partial October 2025) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 13 of 104 days in July, August, September and partial October 2025. This failure could place the residents at risk of not making decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e), in that: The facility failed to designate a qualified person to serve as the director of food service when there is no full-time dietitian. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 (hot water heater for the laundry) of 1 reviewed for essential equipment. The facility failed to repair or replace the water heater that supplied hot water for laundry for 2 months. This failure could place residents at risk of diminishing quality of life and declining health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 (Resident # 9 and Resident #5) reviewed for the physical environment. The facility failed to ensure Resident #9's window blind and chest of drawers were damaged and Resident #5's window blind was damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen observed for evidence of pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of a lizard in the kitchen. The facility's failure placed the residents at risk for foodborne illness and/or disease spread by pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 (Resident #6) of 6 residents reviewed for resident call system, in that: The facility failed to provide a working communication system on 10/10/25 that was easily accessible and that would allow Resident #6 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for administration. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they were due. The facility had a past due balance of four months with the water vendor with a disconnection notice given with a date that had already passed (10/25/25); a past due balance with the electricity vendor for services provided; and a past due balance of two months with the gas vendor with a disconnection notice given with a date that had already passed (11/6/25). This failure could place residents at risk of not receiving essential care and services.

Inspectors wroteBased on record review, observation and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for Administration. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The facility had a past due balance of 4 months with the water vendor with a disconnection notice given with a date that had already passed; and a past due balance of 3 months with the fire vendor for services provided in September 2024 and January 2024. The failure to have sufficient financial resources to pay debts timely had the potential to adversely affect the delivery of essential care and services. [...]

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility did not have RN coverage for 17 days on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. This failure could place the residents at risk of not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 7 residents (Resident #1) reviewed for resident care, in that: The facility failed to ensure Resident #1 was provided an x-ray as ordered by the physician. This failure could place residents at risk for a decline in health status.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the services of an RN for 8 consecutive hours 7 days a week for 22 days out of 79 days and employ a full time DON for 19 of 79 days reviewed for RN coverage from September 2024 to November 2024. The facility failed: - to have an RN for 8 consecutive hours 7 days a week for 22 days from September 1, 2024, through November 18, 2024. - to employ a full time DON for 19 of 79 days from September 1, 2024, through November 18, 2024. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

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 38 of 40 residents as evidence by : The facility failed to ensure: A. The low temperature dishwashing machine did not have a chemical sanitizer and the dietary staff failed to check the chlorine sanitizer content to ensure the dish washing machine was operating correctly to clean and sanitize the dishes consistently each meal; B. The 2 food carts were soiled with dust and food crumbs; C. Open food items were not placed in sealed containers and dated; D. The ice machine had mold at the top of the ice tray; E. The window seal including the window unit air conditioner was soiled with dust and food crumbs; F. The stove and oven were soiled with food and grease; G. [...]

Inspectors wroteBased on interview and record review the facility failed to refer 1 of 3 residents (Resident #13), for PASRR screening and evaluation, with a newly evident mental disorder or a related condition for a level II PASRR review, in that: Resident #13 was not referred to the state-designated authority for a PASRR re-evaluation upon evidence of new diagnoses of major depressive disorder, dated 09/01/2023 and evidence of potential indicator of psychosis on MDS significant change dated 05/01/2024. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 1 of 2 residents (Resident #3) reviewed for a mental illness, intellectual disability, or developmental disability. The facility failed to ensure Resident #3, with an initial admission date of 03/22/18, had a diagnosis of mental illness and a PASARR Level II (PE) screening was not completed. This failure placed residents at risk of mental health needs not being met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 18 residents (Residents # 36, and #38) reviewed for care plans as follows: 1. Resident #36 did not have a comprehensive care plan completed within 14 days of admission. Resident #36 was admitted on [DATE] and his first comprehensive care plan was not completed until 10/6/24. 2. Resident #38 was admitted on [DATE] and did not have a comprehensive care plan completed until the CNO was notified on 11/19/24. Her care plan was then completed on 11/20/24. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record 1 of 13 residents. (Resident #13) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #13 had a proper diagnosis to receive medication (Depakote and Ativan) as ordered. This failure could affect residents who received medications in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents reviewed for infection control. (Resident #9, #28, and #91). 1. The facility failed to place Resident #9 who had a gastrostomy tube (tube into stomach thru abdomen) on EBP. 2. The facility failed to place Resident #28 who had a wound on EBP. 3. The facility failed to place Resident #91 who had a PICC (Peripherally inserted central catheter) on EBP. These failures could place residents at risk for cross-contamination, increased risk of infection and 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 1 of 1 kitchen reviewed. 1. The floors were soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. This failure could place residents at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on interview, and record review the facility failed to accurately assess each resident's status for 1 of 3 Residents (Resident #1) reviewed for assessment accuracy in that: Resident #1's Annual MDS dated [DATE] did not have Section N (under Gradual Dose Reduction) coded correctly to reflect that the resident has received a Gradual Dose Reduction and that the medication is not contraindicated. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.