Palo Pinto Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 (Resident #18) residents who received a pureed meal reviewed during 1 of 1 lunch meals. The facility failed to ensure Resident #18, who received a pureed diet, was provided the food according to the menu, including a roll on 09/09/2025. This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

Inspectors wroteIn an observation on 09/10/2025 at 3:18 p.m., there did not appear to be any survey results in the lobby nor a sign indicating survey results were available and where to locate them. Survey binder observed to be placed in a bin down a hallway to the right of lobby with small print labeled survey results outside of the binder and on the bin. The survey binder did not have results from investigation visit on 04/10/2025 or most recent recertification visit on 08/20/2024. Resident #10Record review of quarterly MDS dated [DATE] reflected Resident #10 was a [AGE] year-old male who admitted into the facility on [DATE] with diagnoses to include: [...]

Inspectors wroteBased on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 (SNA A and SNA B) of 2 Student Nurse Aides reviewed for nursing services. The facility failed to ensure SNA A and SNA B was certified within the required time. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident # 1) of 5 residents reviewed for infection control, in that: The facility failed to implement Enhanced Barrier Precautions for Resident #1 who had an Enhanced Barrier Precautions sign posted on her room door. This failure could affect residents and place them at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 2 (Resident #9 and #24) of 24 residents reviewed for care plans. 1. The facility failed to develop and implement a comprehensive care plan for Resident #24 to address the left femur fracture sustained on [DATE] and current transfer status. 2. The facility failed to update Resident #24's Kardex (a brief digital overview of the resident's needs) to reflect she required 2 people to transfer her. As a result, the resident was transferred on [DATE] by a hospitality aide. Resident #24 was sent to the hospital and sustained a femur fracture. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision/assistance to prevent accidents for one (Resident #24) of four residents reviewed for accidents. The facility failed to ensure Resident #24 was free of accident hazard when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. Resident #24 was required to be non weight bearing and have brace to the left leg after the incident. An IJ was identified on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for three of four dietary staff (Dietary Aide Y, Dietary Aide Z and Dietary Manager) and the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the low temperature dish machine was working properly on 08/20/24 to ensure appropriate chlorine sanitizer ppm levels. 2. The facility failed to ensure the Dietary Aide Y, Dietary Aide Z and the Dietary Manager wore an effective hair restraint during the lunch meal preparation on 08/20/24. 3. The facility failed to ensure Dietary Aide Y and Dietary Aide Z performed hand hygiene during the lunch meal preparation on 08/20/24 These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment which included but not limited to receiving treatment and supports for daily living safely for 2 of 4 residents (Resident #43 and #18) reviewed for a homelike environment. 1. The facility failed to ensure Resident #43's room didn't have food debris, hair and trash under his bed. 2. The facility failed to ensure Resident #43's room window blinds and ledges were dusted or clean. 3. The facility failed to ensure Resident #18's window ledge and blinds were dusted. These failures could place residents at risk for an unsanitary, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for two of two residents (Resident #123 and Resident #67) reviewed for dialysis. 1. The facility failed to ensure Residents #123 and #67's dialysis communication sheets were completed to coordinate care with the dialysis center. 2. The facility failed to ensure residents had physician orders for dialysis treatment and to inspect vascular access sites for Residents #123 and #67. These failures could place residents at risk of not receiving proper care and adequate coordination of care.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #18, Resident #4, Resident #36, and Resident#69) reviewed for infection control. 1. The facility failed to ensure RN I disinfected the blood pressure cuff in between blood pressure checks for Residents #18, #4 and #36. 2. The facility failed to ensure CNA G changed soiled bed linen after she performed incontinence care for Resident # 69. These failures could place residents at-risk of cross contamination which could result in infections or illness.

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 and rodents in the facility's only kitchen, only dining room area, and two of two resident rooms reviewed for pest control. 1. The facility failed to ensure the kitchen was free of flies. 2. The facility failed to ensure resident rooms were free of flies. 3. The facility failed to ensure installed pest control measures in resident rooms and the dining area were operational and clean. These failures could place residents at risk for cross contamination, food borne illnesses, and the spread of infection and disease, and a reduced quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and procedures to investigate any such allegations for one of six residents (Resident #24) reviewed for abuse and neglect. The facility failed to follow their policy for abuse and neglect by not reporting an allegation of neglect within 2 hours when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound, and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 medication carts (Nurses cart hall 3) reviewed for pharmacy services. The facility failed to ensure RN J, responsible for Nurses Cart hall 3, removed medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident had the right to be free from abuse or neglect for 1 of 5 residents (Resident #2), reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse/neglect by CNA B. The failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and psychological damage.

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 disease and infections for one (Resident #1) of two residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 (Resident #1, Resident #3, and Resident #5) of 5 residents reviewed for a clean and comfortable environment. 1. The facility failed to repair the cove base trim at the base of the wall in Resident #1's bathroom that exposed black discoloration, damaged dry wall, and water-damaged wood. The facility failed to repair or replace the linoleum flooring in Resident #1's bathroom observed to be discolored, buckled, and water damaged. 2. The facility failed to repair the cove base trim at the base of the wall in Resident #3 and Resident #5's bathroom under the sink that exposed damaged dry wall and discolored paint. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure parenteral fluids were administered with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident #60 and Resident #220) reviewed for IV therapy. 1. The facility failed to provide adequate maintenance of the PICC line for Resident #60 by not performing a dressing change from 05/12/23 until either 05/26/23 or 05/29/23 (actual dressing change date unclear due to conflicting evidence). 2. The facility failed to provide adequate maintenance by not flushing the IV line, not performing dressing changes, and did not document insertion or removal or IV lines for Resident #220. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 meal reviewed. The facility failed to follow the recipe when preparing the mechanical soft hamburger patty. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 of 10 residents (Residents #1, #26 and #8) reviewed during the lunch meal. The facility failed to ensure Resident #1, Resident #26 and Resident #8 received a dessert or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

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 reviewed for kitchen sanitation. 1. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. 2. The facility failed to ensure all food was not past the expiration date. 3. The facility failed to ensure staff utilized proper personal hygiene practices. 4. The facility failed to ensure dietary staff cleaned kitchen counters between pureeing different foods. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #220) reviewed for dialysis. The facility failed to ensure Resident #220 had orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of infection or bleeding, edema, blood pressure, or fluid overload. This failure could place residents at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order for one of two residents (Resident #46) reviewed for unnecessary medications. The facility failed to ensure Resident #46 did not have an order for the psychoactive medication diazepam (Valium) PRN for more than 14 days, without an evaluation by Resident #46's physician for the appropriateness of the medications. This failure could place residents at risk for receiving unnecessary medications.