Skilled Care of Mexia

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for one of one (Resident #1) reviewed for accidents and supervision. The facility failed to prevent the elopement of Resident #1 on 10/5/2025. The noncompliance was identified as past noncompliance. The immediate jeopardy began on 10/16/2025 at 5:22 p.m. and ended on 10/17/2025 at 5:58 p.m. The facility had corrected noncompliance before the investigation began. This failure could place residents at risk for accidents and harm.

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 of 4 residents [TF1] (Resident # 18, Resident #83, and Resident #37) and two of Two staff (interviewed and reviewed for infection control. Based 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 of 4 residents Resident # 18, Resident #83, and Resident #37) and two of Two staff (interviewed and reviewed for infection control. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and times to meet a resident's need for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. 1. The facility failed monitor Resident #1's monthly weights. 2. The facility failed to develop, and implement, a person-centered intervention for Resident #1's severe weight loss that began on 8/24/2024. The noncompliance was identified as PNC IJ. The IJ began on 08/24/2024 and ended on 11/18/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This failure could place residents at the facility at risk of malnutrition.

Inspectors wroteBased on interviews and record review, the facility failed to unsure residents maintained acceptable parameters of nutritional status, such as usual body weight, for 1 of 5 residents (Resident #1) reviewed for nutritional status. The facility failed to identify Resident #1's severe weight loss at a 30-day, 90-day, and 180-day increment on 8/24/2024, 9/2/2024, 10/2/2024, and 11/5/2024. The noncompliance was identified as PNC IJ. The IJ began on 08/24/2024 and ended on 11/18/2024. The facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This failure could place residents at the facility at risk of malnutrition.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents' assessments accurately reflected the residents' statuses for 1 of 5 Resident (Resident#1) reviewed for accuracy of assessments. The facility failed to identify Resident #1's severe weight loss on a Quarterly MDS Assessment, dated 10/4/2024, at 180 day look back increment. This failure could place residents at the facility at risk of malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 1 of 8 residents (Residents #20) reviewed for resident rights, in that: On 05/29/24 CNA A failed to knocked or requested permission before entering Resident #20's room. This deficient practice could place residents at risk of psychosocial harm due to diminished self-image and could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 1 medication storage rooms reviewed for pharmacy services. The facility failed to ensure one medication PPD (total of 1 vial) were not dated with opened date in the medication storage room refrigerator. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare food in a form to meet individual needs for 1 of 8 (Resident #20) residents observed for dietary needs. The facility failed to ensure Resident #20 received food that was in a form to meet Resident 20's needs. This failure could contribute to causing a resident to choke and poor food intake.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents had right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other resident for 1 of 5 residents (Resident #1) reviewed for resonable accommodations. The facility failed to ensure CNA A did not remove Resident #1's call light and beside table from within her reach which prevented the resident from calling for assistance when needed. This failure could place residents at risk of being neglected by staff if they were unable to call for assistance when needed. The noncompliance was identified as PNC. The noncompliance began on 3/20/2024 and ended on 3/27/2024. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of fifteen residents (Resident # 39, Resident # 57 and Resident #10) reviewed for quality of care. The facility failed to ensure Resident # 39's, Resident #57's and Resident #10's nails were trimmed and cleaned. These failures placed residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 2 of 8 Residents (Resident #39 and Resident # 58) reviewed for call lights in that: Resident #39 and Resident #58 were observed in their rooms with their call lights not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 7 residents (Resident #3 & #37) reviewed for resident assessment and care screening. Facility failed to accurately complete the minimum data set for Resident #3's and Resident #37's oxygen therapy. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

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 residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 2 of 7 residents (Residents #3 & #37) reviewed for care plans. 1. Resident #3's comprehensive care plan did not address the resident's use of oxygen. 2. Resident #37's comprehensive care plan did not address the resident's use of oxygen. These deficient practices could place residents at risk of receiving inadequate interventions that were not individualized to their care needs.

Inspectors wroteBased on observation, interview and record review, the facility must ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice one (Resident #39) of two oxygen concentrators reviewed for essential equipment. The facility failed to change nasal cannula tubing of Resident #39 as ordered by the physician. This failure could affect the resident by increasing the risk of respiratory infection.

Inspectors wroteBased on observation, 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 and transmission of communicable diseases and infections for one resident (#35) of two residents observed for infection control in that: After using the blood pressure machine on Resident #55, CMA D did not sanitize the Blood pressure machine prior to placing the blood pressure machine on Resident #35 to measure blood pressure. This deficient practice could place the facility's residents at risk of infection while having their blood pressure taken in the facility and could result in cross contamination of germs.