Reagan County Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: Record review of Resident #1's face sheet dated 01/14/2026 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) depression (a serious mood disorder causing persistent sadness, loss of interest and affecting thoughts) and chronic kidney disease (progressive damage and loss of function…

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 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. The findings included: Record review of the PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2025 (October 1 - December 31) dated 05/12/2025, revealed the following entry: Failed to Submit Data for…

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 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. Finding included: 1. Record review of Resident #2's electronic admission record dated 05/14/2025 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s disease and aphasia (difficult talking). He was [AGE] years of age. Record review of Resident #2's care plan revised 11/22/23 indicated in part: Focus: Resident has frequent bladder and bowel incontinence. Is at risk for skin breakdown and infection. GOAL: Resident will have…

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 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. Findings included: Record review of Resident #21's electronic admission record dated 05/13/2025 indicated he was admitted to the facility on [DATE] with diagnoses of overactive bladder and Parkinson's disease. He was [AGE] years of age. Record review of Resident #21's care plan revised 12/18/24 indicated in part: Focus: Resident has foley catheter due to Benign prostatic hyperplasia with urinary retention. Will refer him to Urologist (doctor who focuses on the diagnosis and treatment of conditions related to the urinary [NAME]). GOAL: Resident will be/remain free…

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, 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. The findings included: During an observation on 05/13/25 at 10:05 AM the facility Ground Maintenance Man D was observed in the kitchen while food was being prepared by the kitchen staff. Ground maintenance man D was observed to have a moustache and beard which was not covered. On the kitchen entrance door was a posted sign that indicated Notice hairnets and beard must be covered beyond this point. During an interview on 05/14/25 at 3:45 PM Ground Maintenance Man D said that he normally wore a face mask when he…

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, 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. The findings included: Observation on 04/03/24 at 12:40 PM of back patio area/smoking area revealed approximately fifteen feet straight out from the door, was a large circle (approximately 10 feet in diameter) of rocks with a tree planted in the center. There was visible cat feces in several spots as well as multiple areas of dirt that had been dug out by an animal with claw marks visible in the dirt. The places that had been dug out were surrounding the base of the tree and all rocks had been removed from the area. There was a slight fecal odor noted to the area. In an interview on 04/03/24 at 01:09 PM the Maintenance Director stated that he had his guys go out 2-3 times a week…

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 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. Resident #11 was admitted with diagnoses including atherosclerotic heart disease (thickening of arteries), dementia (progressive loss of intellectual functions), anxiety disorder (excessive worry), major depressive disorder (persistent depressed mood). Record Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a BIMs…

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 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. Finding include: RESIDENT #5 Record review of Resident #5's admission record dated 04/03/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia and chronic obstructive pulmonary disease (a chronic condition in which a patient's lungs are…

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 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. The findings included: Record Review of Resident #11's face sheet revealed an [AGE] year-old female with an admission date of 04/11/17. Resident #11 was admitted with diagnoses including atherosclerotic heart disease (thickening of arteries), dementia (progressive loss of intellectual functions), anxiety disorder (excessive worry), major depressive disorder (persistent depressed mood). Record Review of Resident #11's Quarterly…

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 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. The findings included: During observation and interview on 4/4/24 at 1:25 PM with the ADON of the discontinued controlled medication cabinet in the DON's office it was noted that the cabinet only had one functioning lock. The medications were stored in the bottom drawer of a two-drawer filing cabinet that was bolted to the wall. The bottom drawer had an external pad lock on the left side of the bottom drawer and the built-in lock on the top right side to lock both drawers. The ADON stated that the built in lock was a…

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, 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 residents, 1 of 2 Medication Carts and 1 of 1 Medication Storage Rooms reviewed for pharmacy services. - The facility failed to ensure Medication Cart #1 did not include an expired box of Hyoscyamine SL tablets, Ondansetron tablets, and AZO Bladder Control tablets. - The facility failed to ensure the Medication Storage Room did not contain an expired box of Thick and Easy Food and Beverage Thickener, and Promethazine HCL suppositories. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Medication Cart #1 In an observation 02/22/23 at 3:50PM, inventory of Medication Cart #1 with LVN A revealed: - a box of Hyoscyamine SL tablets 0.125mg, expired 11/05/22 - a box of Ondansetron tablets 4mg,…

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 interview and record review, the facility failed to ensure dialysis service was provided consistently with professional standards of practice for 1 of 2 residents (Resident #25) reviewed for dialysis services. The facility failed to keep ongoing communication with the dialysis facility for Resident #25. The facility failed to have a contract with Resident #25's providing dialysis center prior to 02/23/23. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Review of Resident #25's admission Record, dated 2/21/23, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnosis including Stage 5 Kidney Disease and Dependence on Renal Dialysis. Review of Resident #25's Significant Change MDS, dated [DATE], revealed: He had a cognitive status exam score of 12 of 15 (indicating he was moderately cognitively impaired). He needed one person assistance for…

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.