Palo Duro Nursing Home

Inspectors wroteBased on interview, observations and record review the facility failed to provide, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 12 residents reviewed for activities. A. The facility failed to follow the activity calendar for August. B. The facility activity calendar for August failed to incorporate physical activities and interaction in the community into its activity programs. These failures could place residents at risk of reduced quality of life and boredom in life by not receiving activities to meet their individual needs.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for the months of April 2025, May 2025, June 2025, July 2025 and August 2025 .for weekend RN coverage. A. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: April 202504/13/25, 04/19/25, 04/20/25 May 202505/03/25, 05/10/25, 05/11/25, 05/17/25, 05/18/25, 05/24/25, 05/25/25 June 202506/1/25, 06/7/25, 06/08/25, 06/14/25, 06/15/25, 06/22/25 July,2025 07/05/25, 07/6/24, 07/12/25,07/13/25, 07/19/25, 07/20/25, 07/26/25, 07/27/25 August,202508/02/25, 08/03/24, 08/09/25, 8/10/25, 08/16/25 and 08/17/25 This failure could place residents at risk for inconsistency in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 12 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's catheter drainage bag was covered and urine in the bag was not visually exposed. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment accurately reflected resident's status for 2 (Resident #3 and #30) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #3 for the use of oxygen on her 06/08/25 annual MDS. -The facility failed to accurately assess Resident #30 for wight loss on his 07/24/25 quarterly MDS. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 12 residents (Resident # 6) reviewed for trauma-informed care. The facility did not ensure Resident #6 had a trauma screening that identified possible triggers when Resident #6 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 (CNA A) of 5 CNA's were certified in accordance with applicable state laws. CNA A worked 7 days in the facility with an expired CNA certification. The deficient practice of failing to ensure employee certifications could affect all residents by exposing them to inadequate care resulting in deterioration of their conditions.

Inspectors wroteBased on interviews, and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, consistent with their expected roles. The facility failed to ensure Abuse, Neglect and Exploitation Training, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia Training were completed upon hire for 2 of 5 employees (Marketing/Admissions Coordinator and CNA A) reviewed for required trainings. Based on interviews, and record reviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, consistent with their expected roles. [...]

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 observed for food storage, preparation, and distribution. A. The DM did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination.

Inspectors wroteBased on interviews and record review the facility failed to assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months for 5 (Residents #4, #11, #18, #21, and #31) of 12 residents reviewed for quarterly MDS assessments. 1. The facility failed to complete a quarterly MDS for Resident #4 with ARD 06/13/24. 2. The facility failed to complete a quarterly MDS for Resident #11 with ARD 05/24/24. 3. The facility failed to complete a quarterly MDS for Resident #18 with ARD 05/07/24. 4. The facility failed to complete a quarterly MDS for Resident #21 with ARD 06/14/24. 5. The facility failed to complete two quarterly MDS' for Resident #31 with ARDs 05/20/24 and 06/14/24. These failures could lead to residents not receiving necessary/complete/correct care due to lack of current information for care plans.

Inspectors wroteBased on interviews and record review the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review for 2 (Resident #5 and Resident #11) of 12 residents reviewed for PASRR. 1. The facility failed to refer Resident #5 for PASRR level II review following a diagnosis of bipolar disorder one day after he was admitted to the facility. 2. The facility failed to refer Resident #11 for PASRR level II review following a diagnosis of psychotic disorder almost 6 years after he was admitted to the facility. These failures could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: 1. [...]

Inspectors wroteBased on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 (Resident #31) of 12 residents reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #31 until 27 days after he was admitted . This failure could place residents at risk of receiving inadequate care. Findings Included: [...]

Inspectors wroteBased on interviews and record review the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #5) of 12 residents who were reviewed for accuracy of medical records. The facility failed to recognize Resident #5's PASRR level 1 was incorrect in that he was positive for mental illness due to his diagnosis of bipolar disorder. This failure could place residents at risk of harm by mentally unstable residents and/or at risk of not having their mental health needs met. Findings Included: [...]

Inspectors wroteBased on observations, interviews, 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 4 (LVN B, CNA C, CNA D, and CNA E) of 4 staff members. -LVN B did not don PPE gown before or during performing ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA C did not don PPE gown before or during assisting ordered Wound Care to unstageable pressure ulcer to sacral area of Resident #187 who also had a Foley Catheter. -CNA D did not don PPE gown before or during performing ordered Foley Catheter Care to Resident with unstageable pressure ulcer to sacral area on Resident #187. [...]

Inspectors wroteBased on observation, 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 6 residents reviewed for comprehensive care plans. Resident #1 required partial/moderate and substantial assistance in self-care activities which were not documented in his care plan. Resident #1 had diagnoses of depression, anxiety and dementia(loss of memory)which were not documented in his care plan. [...]

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 and 1 of 1 kitchen storage room reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure foods were sealed properly. 3. The facility failed to properly sanitize thermometer to check food temperatures. 4. The facility failed to ensure proper thawing procedures. 5. The facility failed to ensure proper infection control measures. 6. The facility failed to check expiration dates on foods. 7. The facility failed to properly cover/seal foods. These deficient practices could expose residents who consume food prepared in the facility's kitchen to food-borne illnesses. Findings Include : [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 (Resident #22, Resident #31, and Resident #32) of 12 residents reviewed for DNR orders. Resident #22 had an OOH-DNR order that was not completed as it was not dated by the physician, did not have the printed name of the physician, and was not signed a second time by one of the witnesses. Resident #31 had an OOH-DNR order that was not completed as it was not dated by the physician, one of the witnesses did not sign a second time, and it was not dated in the final section titled, ALL PERSONS MUST SIGN HERE:. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 3 of 12 residents (Residents #15, #22, and #29) reviewed for PASRR compliance. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #15 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #22 prior to admission to the facility. The facility failed to ensure that an initial PASRR screening (Level I screen) was completed for Resident #29 prior to admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 5 of 12 residents (Residents #19, #22, #31, #32, #33) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to complete goals related to smoking for Residents #22, #32, #33 2. Failure to create goals of services being provided such as hospice care for Resident #31 3. [...]

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 3 (CNA D, RN A and CNA E) of 3 staff observed for infection control practices. -CNA D failed to use proper hand hygiene techniques when providing incontinent care to Resident #30. -RN A failed to use proper hand hygiene when delivering meals in dining area. -CNA E failed to use proper hand hygiene when assisting resident with meal tray in resident room. This failure may place resident at an increased risk for transmissible diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 12 residents (Resident #4) reviewed for accuracy of MDS assessments. The facility failed to identify Resident #4's administration of Humalog Solution (insulin lispro) injections on his annual MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk and could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep resident environment free of accidents and hazards and assistance devices to prevent accidents for 1 of 12 residents (Resident #19) reviewed. The facility failed to provide a fall mat for Resident #19. This failure can increase the risk of injury for residents requiring assistance due to history of falls.