Reagan County Care Center

Inspectors wroteBased on record review and interview, the facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 5 of 5 years (2021, 2022, 2023, 2024, and 2025) reviewed for facility assessment. The facility failed to conduct a Facility Assessment since 2021. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms that had Tuberculosis solution that was not labeled with an open date. The facility failed to ensure one Tuberculosis solution was labeled with the open date. This failure could place residents at risk of adverse medication reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing information in a prominent place readily accessible for visitors, staff, and residents for 1 of 1 facility reviewed on 6/30/2026, 7/1/2026, and 7/2/2026 for nursing services. The facility failed to post the daily nurse staffing information in a readily accessible place for visitors, and residents. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete an accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS (Centers for Medicare & Medicaid Services) 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 . The facility failed to submit Payroll Based Journal staffing information to CMS for the fiscal year Quarter 1 2025 (October 1 - December 31). The facility's 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 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 1 of 2 residents (Resident #2) reviewed for incontinent care. The facility failed insure CNA A changed her contaminated gloves and clean Resident #2's penis area during incontinent care. These failures 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 review and revise the care plans for 1 of 4 residents (Resident #21) whose care plans were reviewed in that: The facility failed to ensure Resident #21's care plan was revised to accurately reflect current indwelling urinary foley catheter status that was removed on 02/12/2025. These failures could place residents at risk of receiving inadequate individualized care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 Maintenance personnel (Ground Maintenance D) reviewed for kitchen sanitation in that: The facility failed to ensure Ground Maintenance D was wearing a moustache guard or a beard guard when he was in the kitchen and while staff was preparing uncovered food. These deficient practices could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 1 back patio reviewed for environment. The facility failed to keep a landscaped area on the back patio free of cat feces. This failure could lead to unsanitary conditions for residents and staff and possible parasitic infection.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 (Resident #11) of 28 residents reviewed for assessments, in that: The facility failed to complete a Significant Change MDS for Resident #11 within 14 days after the resident was admitted to hospice services. This failure could affect any resident who experienced a significant change in their condition requiring an MDS assessment and placed them at risk of not receiving needed services. Findings Included: Record Review of Resident #11's face sheet revealed an [AGE] year-old female with an admission date of 04/11/17. [...]

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, #6 and #26) of 5 residents reviewed for infection control. Staff failed to place Resident #5's and #26's SVN (a machine that mixes medicine and converts it into a mist.) masks in a bag when not in use. CNA A failed to wash or sanitize her hands after removing her gloves and putting on a clean pair of gloves while assisting Resident #6 with incontinent care. This failure could place residents at risk for cross contamination and the spread of infection.

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 1 of 28 residents (Residents #11) reviewed for care plans in that: The facility failed to ensure Resident #11's Care Plan addressed her hospice status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation and interview the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments (DON's office) reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. This failure could place residents at risk of drug diversion and unauthorized access to medications.