Concho Health & Rehabilitation Center

Based on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for accuracy and completeness.Facility failed to document that Resident #1 wound care was completed on 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. This deficient practice could put residents at risk of not receiving needed services although services are documented as having been provided. Record review of Resident #1's detailed summary report/face sheet dated 12.18.25 indicated he was admitted to facility on 11.17.25 with diagnoses of heart failure, anemia, and type 2 diabetes. Record review of Resident #1's Minimum Data Set (MDS) dated 11.25.25 indicated the Brief Interview Mental Status (BIMS) score = 14 indicating resident had no impairment. Record review of Resident #1's care plan dated 12.18.25 indicated the resident has a pressure ulcer or potential for pressure ulcer development. The resident's pressure ulcer will…

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 interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 5 Residents (Resident #1) reviewed for Abuse. The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #1 alleged abuse occurred during a recent hospital visit. This deficient practice could delay assessment and care of residents who report abuse. The findings were:Record review of Resident #1 's face sheet dated 10/17/25 revealed a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE] after observation stay at Hospital #1 for delirium (a state of acute mental confusion and disorientation that can cause significant changes in a person's…

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 develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described services that attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. : The facility failed to ensure a Care Plan was developed to address Resident #2's dry skin (skin was not falling off the body the way it should). This failure could place residents at risk of not receiving individualized care and services to meet their needs. The findings include:Record review of Resident #2's admission Record, dated 7/23/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included…

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 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 one (Resident #7) of two residents reviewed for infection control practices. LVN A failed to sanitize the glucometer with a germicidal wipe after she performed a blood sugar check on Resident #7. This failure could affect the residents by placing them at risk for the spread of infection. Finding include: Record review of Resident #7's admission record, dated 07/24/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included diabetes mellitus type 2 and chronic kidney disease. Record review of Resident #7's Medication Order summary, dated 07/24/25, revealed she received Insulin Solution (Insulin Asp art) subcutaneously before meals and at bedtime per…

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, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen in that: The facility failed to ensure kitchen staff wore facial hair restraints during meal preparation. These failures could place residents who received meals prepared in the kitchen at risk for food borne illness and cross-contamination. Findings include: During an observation and interview on 05/21/24 at 10:24 AM Dietary [NAME] D and Dietary Aide C were not wearing facial hair restraints as they each had a moustache and beard. Dietary [NAME] D and Dietary Aide C said they normally wore their facial hair restraints but had forgotten to put them on this morning. There was food set out such as chicken and cake which both staff members were currently preparing when seen without the restraints. During an interview on 05/22/24 at 10:54 AM the Dietary Manager said when staff were in the kitchen, they were supposed to wear hair restraints including facial hair restraints. 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 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, #9 and #31) of 5 residents reviewed for infection control. The facility failed to ensure: CNA E did not turn off the faucet with her bare hands after washing them and before performing personal care for Resident #5. CNA's E and F change their gloves after they became contaminated during incontinent care while assisting Resident #9. CNA B change her gloves after they became contaminated during incontinent care while assisting Resident #31. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: RESIDENT #5 During an observation on 05/21/24 at beginning at 02:46 PM CNA E entered Resident #5's bathroom and rinsed her hands (no soap was used), turned off the faucet…

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 ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident hazards/supervision (Resident #5). The facility failed to ensure CNA E and G demonstrated appropriate transfer techniques while using the mechanical lift for Resident #5. These failures could place residents at risk for injuries. Findings included: Review of Resident #5's admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fibromyalgia (a condition causing widespread pain and fatigue) and reduced mobility. Review of Resident #5's state MDS assessment dated [DATE] revealed: She had a mental status score of 6 of 15 (indicating severe cognitive impairment) She needed extensive assistance of two or more people to transfer between bed and wheelchair. Observation and interview on [DATE] at 02:34 PM revealed Resident #5 was in her…

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 ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 2 medication carts (Med Cart #1), reviewed for labeling/storage of drugs and biologicals. The facility failed to secure controlled medication in a locked compartment. These failures could place the facility at risk of drug diversion and access to medications. Findings included: Observation of the facility Med Cart #1 on 05/21/24 at 03:27 PM with LVN A revealed one sublingual morphine medication blister pack in the regular section of the chart instead of in the locked narcotic drawer. An interview with LVN A on 05/21/24 at 03:50 PM LVN A stated she did not remember putting the morphine in the regular part of the med cart. LVN A stated she must have just grabbed all the medication packs and put them in the regular section. LVN A stated that she knows all narcotics need to be in the locked part of the medication for safety reasons. LVN A stated at the beginning and end of the shift 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 interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 10 residents (Resident #44, Resident # 148) reviewed for resident rights . The facility failed to obtain informed consent from Resident #44 prior to administering Bupropion, an antidepressant used to treat depression. The facility also failed to obtain informed consent from Resident #44 prior to administering Duloxetine, an antidepressant used to treat depression in adults and generalized anxiety disorders (excessive worry and tension that disrupts daily life and lasts 6 months or longer). The facility failed to obtain informed consent for Resident #148 for Seroquel…

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 3 of 12 residents (Residents #5, #20, and #32) reviewed for care plans in that: Resident #5 did not have a care plan to address her pain. Resident #20 did not have a care plan to address her pain. Resident #32 did not have a care plan to address her Alzheimer's/Dementia or pain. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #5's admission Record dated 4/12/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included arthritis. Record review of Resident #5's Annual MDS Assessment, dated 3/27/23, revealed: She scored 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 observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 10 of 41 residents (Residents #6, #10, #11, #13, #14, #17, #18, #25, #28, #32) reviewed for safe, functional equipment, in that: Residents #6, #10, #11, #13, #14, #17, #18, #25, #28 and #32 wheelchairs, to include the brakes, were not in safe working order. These failures could place residents at risk for skin issues, discomfort, and falls. Findings included: Observation, interview and record review on 4/11/23 at 3:40 PM during resident council meeting Resident #18 complained the brakes on her wheelchair were loose and that she was concerned because she knew most of the other wheelchairs in the building had similar issues. Resident #11 stated that her wheelchair brakes were also loose and had wobbly wheels but, she stated she had not reported it to anyone. On Inspection, the wheelchair brakes did not properly engage on either wheel of the wheelchair for Resident #18, #11, #10, #25 and #32. The brakes would lock but were not tight and 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 observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents hazards/supervision/devices, in that: (Resident #42). CNA A failed to complete an appropriate one-person gait belt transfer. This failure could place residents at risk of inadequate supervision and preventable injuries. Findings included: Review of Resident #42's admission Record dated 4/11/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anorexia (lack of appetite causing abnormal weight loss), dementia with behavioral disturbance , muscle weakness, lack of coordination, and stroke. Resident #42 was on hospice services. Review of Resident #42's Significant Change MDS, dated [DATE], revealed: He scored a 6 of 15 on his mental status exam (indicating severe cognitive impairment) He needed stand by assistance of two staff for transfers. Review 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, 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 for 1 of 3 medication carts and 1 of 1 surplus-stocked medication cart reviewed for medication storage. Medication Cart #1 had seven (7) expired medications. Medication Surplus Cart had one (1) expired controlled medication of ten (10) capsules in the med storage room, available for use. This failure could place residents at risk for not receiving the therapeutic effects of the medications ordered. The findings included: Observation on 04/12/23 at 08:30 AM, of surplus-stocked medication cart, revealed: - Temazepam 7.5mg (10 capsules) expiration date 3/11/23 Interview on 04/12/23 at 09:00 AM , the ADON stated that the Consulting Pharmacist checked the locked medication cart in the medication storage room. She stated the Consulting Pharmacist rotated a review of medication in the medication storage room followed by…

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.