Pauls Valley Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged during hospitalization for 1 (#40) of 3 sampled residents reviewed for discharge.The DON identified 36 residents resided in the facility. Findings:An undated facility Bed-Holds and Returns policy read in part, If a Medicaid resident exceeds the state bed-hold period, he or she will be permitted to return to the facility .provided that the resident .a. Requires services of the facility; and b. Is eligible for Medicare skilled nursing services or Medicaid nursing services .If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return or the resident exceeds the 30 days out of facility as noted in the facility that resident will be formally discharged . In event that occurs resident will have to request admission through the facility referral/admission process. The resident will be permitted to return to an available bed in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a:a. bed hold policy upon transfer;b. discharge notice to the resident and/or representative; andc. copy of the discharge notice to the ombudsman for 1 (#40) of 3 sampled residents reviewed for discharge.The DON identified 36 residents resided in the facility. Findings: An undated facility policy Bed-Holds and Returns, read in part, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #40's discharge return anticipated resident assessment, dated 09/30/25, showed the resident had an unplanned discharge to a short-term general hospital stay on 09/30/25. The assessment showed the resident had diagnoses which included recurrent unspecified major depressive disorder and anxiety. The assessment showed Resident #40's memory was OK and was independent in cognitive skills for daily decision making. A nursing note, dated 09/30/25, showed Resident #40 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were completed within 14 days for 1 (#3) of 12 sampled residents reviewed for comprehensive assessments.The DON identified 36 residents resided in the facility.Findings:An undated diagnoses report showed Resident #3 was admitted on [DATE].An annual assessment for Resident #3 showed an assessment reference date of 06/25/25. MDS Coordinator #1 and the DON signed the assessment as completed on 08/05/25.On 12/18/25 at 3:37 p.m. MDS coordinator #1 stated Resident #3's annual assessment, dated 06/25/25, was not completed or transmitted until 08/05/25. They stated it was not completed or transmitted timely. They stated the assessment should have been completed by the 14th day after the assessment reference date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the initiation of a comprehensive nutrition care plan for 1 (#1) of 12 sampled residents reviewed for care plans.The DON identified 36 residents resided in the facility.Findings:An undated admission record for Resident #1 showed the resident admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and diabetes mellitus.A care plan for Resident #1, initiated on 07/16/25, did not show Resident #1 had a nutritional care plan.On 12/16/25 at 1:04 p.m., MDS coordinator #1 stated care plans were to be completed within 21 days of admission and updated quarterly.On 12/16/25 at 1:05 p.m., MDS coordinator #1 stated care plans were updated with different things, falls, when resident has changes. They stated it was a bit complicated to keep up with both care plans and MDS assessments, but it was more complicated to keep up with care plans.On 12/16/25 at 1:10 p.m., MDS coordinator #1stated they did not see a nutritional care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and submit quarterly reviews of the minimum data set in the required timeframe's for eight (#3, 7, 11, 12, 14,16, 17, and #23) of 10 residents whose clinical records were reviewed for completion/submission of the resident assessments. The administrator identified 34 residents. Census: 34 Findings: The facility's MDS Completion and Submission Timeframe's policy, dated 10/01/10, read in part our facility will conduct and submit resident assessments in accordance with federal and state submission timeframe's . On 04/16/24 at 11:30 a.m., the corporate regional director documented the following as the last completed/submitted minimum data set assessments for the following residents: - a quarterly assessment dated [DATE] for Resident #3 - a quarterly assessment dated [DATE] for Resident #7. - an admission assessment dated [DATE] for Resident #11. - a significant change assessment dated [DATE] for Resident #12. - a quarterly assessment dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to develop a comprehensive person-centered care plan for two (#1 and #80) of 12 residents reviewed for care plans. The facility failed to develop care plans related to: a) smoking for resident #1 and #80, and b) falls for one resident #80. The Administrator reported 34 residents resided in the facility. Findings: The facility's Care Plans - Comprehensive policy, dated 10/01/10, read in part An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each residents comprehensive care plan is designed to: a. incorporate identified problems area; b. incorporate risk factors associated with identified problems . 1. Resident #1 had diagnoses which included paraplegia and neurological conditions. A smoking assessment, dated 05/16/23, documented resident #1 is a supervised smoker d/t inability to light cigarette and difficulty disposing of cigarette into receptacle. A smoking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide wound care in a manner to reduce the risk of infection or cross contamination for one (#17) of two residents observed for wound care. The director of nursing identified 4 residents with wounds. Resident census: 34 Findings: On 04/16/24 at 11:00 a.m., LPN #1 was observed to perform wound care on Res #17. The LPN washed hand and donned gloves. With gloved hands, the LPN borrowed an overbed table from the resident's roommate, removing the roommates personal possessions from the overbed table but not sanitizing the table. With the same gloves, the LPN opened and clear plastic shoe box shaped container, laying the lid on the inside facing up. With the same gloves, the LPN remove the contents needing for the dressing change and laid them atop the overbed table. With the same gloves, the LPN removed a positioning pillow from under the resident's hip/leg. One side of the pillow case appeared brown and wet with fecal incontinence. The LPN observed the condition of the pillow case and stated to the resident that after wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to store hazardous chemicals in a secure manner. The director of nursing identified one wandering resident who ambulated throughout the facility. Facility census: 34 Findings: The facility policy entitled Storage Areas, Maintenance, documented hazardous/harmful chemicals were to be stored as instructed on the labels of such products and in a locked storage area. The MSDS (Material Safety Data Sheet) for Virex II - 256 disinfectant documented the chemical was corrosive to eyes, nose, throat, and respiratory tract. The MSDS documented the chemical was combustible and was intended for commercial or industrial use only. It documented to keep the chemical out of reach of children. The MSDS for Good Sense Liquid Air Freshener documented the chemical caused serious eye irritation and not to breath in vapors, taste, or swallow the chemical. The MSDS for Spraybuff, an industrial cleaning chemical, documented the chemical may be harmful if swallowed, may cause eye, skin, and respiratory irritation, and to keep out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen. There was standing water in the kitchen, an active water leak from the three compartment sink, and broken/missing floor tiles. This had the potential to effect all residents. The administrator identified 34 residents resided in the facility. Findings: On 04/14/24 at 12:46 p.m., the kitchen was observed. There was an active water leak from under the three compartment sink. There were several saturated bath sheets and towels on the floor between the three compartment sink and the food prep table. There were several missing, cracked, and broken floor tiles observed. The back door was opened wide and there was no screen door present. On 04/14/24 at 12:50 p.m., cook #1 stated when they arrive each morning to start their shift, there was always standing water all through the kitchen that they would have to mop up before starting breakfast. The cook stated the leak from under the three compartment sink had been there awhile and maintenance had been notified. On 04/16/23 at 4:34 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure the resident's representative was included in discharge planning for one (#30) of three residents reviewed for discharges. The Administrator reported 34 residents resided in the facility. Finding: The facility's Resident/Family Participation - Assessment/Care Plans policy dated 12/01/2006, read in part The resident and his/her family, and/or legal representative, are invited to attend and participate in the resident's assessment and care planning conference .The social services director or designee is responsible for contacting the resident's family and maintaining records of such notices . 1. Resident #30 had diagnoses which included heart failure, respiratory failure, and diabetes mellitus. A care plan, dated 08/25/23, documented Discharge planning: Resident, family and staff are in agreement for discharge planning .Planned discharge date is 09/01/23 .Goal: able to return home with supportive services 09/01/23 .Intervention: Notify provider of concerns. Assist with obtaining community services. Assist in ordering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to electronically transmit MDS assessments, within 14 days after completion, for 11 (#1, 4, 5, 6, 9, 14, 19, 20, 22, 23, and #24) of 11 residents reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: On 03/10/23 at 10:19 a.m., the facility's regional consultant was interviewed regarding MDS resident assessments not being transmitted as required. The consultant reported they had recognized a problem with MDS assessments on 02/01/23. The consultant stated the facility previously did not have an RN in their system to sign off on MDS assessments, and they believed this was part of the issue with the assessments either not being transmitted or being transmitted late. On 03/10/23 at 11:16 a.m., the regional consultant provided a list of residents who were identified as having MDS assessments completed but not transmitted in the required timeframe. The consultant reported they had transmitted a batch of MDS assessments over the past couple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure: a. an Oxygen in Use sign was in place per the facility's policy and, b. oxygen tubing was labeled with date and initials when changed per professional nursing standards for two (#1 and #178) of two residents reviewed for oxygen therapy. The Resident Census and Conditions of Residents, dated 03/08/23, documented 21 residents resided in the facility. Findings: The facility Oxygen Administration policy, dated 04/01/22, read in parts, .Place an 'Oxygen in Use' sign on the outside of the room entrance door .Place an 'Oxygen in Use' sign in a designated place on or over the resident's bed . 1. Resident # 1's cognition was documented to be severely impaired and had a diagnoses of COPD. admission Orders for resident #1, dated 02/22/23, read in part, .Check SpO2 every shift, if < 93% place on oxygen 3 lpm via nc . Resident #1's Care Plan, dated 02/22/23, read in parts, .The resident is receiving PRN oxygen therapy related to COPD .Goal: The resident will maintain SpO2 above 93% through the next review date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to designate a registered nurse to serve as the Director of Nursing on a full time basis. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: On 03/08/23 at 9:43 a.m., the Administrator reported she had been at the facility since 02/01/23 and the facility had not had a Director of Nursing during that time. The Administrator stated the new DON had just started working half-days and would be at the facility full-time beginning 03/13/23. The Administrator reported a corporate nurse had been coming in occasionally and offering assistance as needed but did not fulfill the duties of DON. On 03/10/23 at 10:26 a.m., the regional consultant reported the last full time DON had resigned on 01/01/23. The consultant reported there was no DON coverage from 01/01/23 until 03/06/23 when the new DON started part-time, and the DON would be full time effective 03/13/23. The consultant reported she had called to request a waiver but was under the impression she did not need a waiver as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to act upon a pharmacy recommendation, to consider a dose reduction of an antipsychotic medication, for one (#9) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 21 residents resided in the facility. Findings: A facility policy, Medication Regimen Reviews, revised May 2022, documented in parts, .Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physician .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record . Resident #9 had diagnoses which included Bipolar disorder, dementia with behaviors, and anxiety. An Annual MDS Assessment, dated 09/28/22, documented the resident was cognitively intact. The assessment documented the resident received antipsychotics seven of seven…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.