Focused Care At Lamesa

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, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #1) of 5 residents reviewed for care plans. The facility failed to develop a care plan for use of a Wander Guard electronic signaling device, utilized for wander-management, for Resident #1. This failure could place residents at risk of not receiving the care required to meet their individualized needs.Record review of the admission record for Resident #1, dated 04/14/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: dementia without psychosis, history of falling, unsteadiness on feet, and weakness. Record review of the quarterly MDS assessment for Resident #1, dated 01/23/26, revealed…

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 that the menus were followed for 1 of 1 meal (lunch meal) on 01/07/2026 reviewed for meal accuracy, in that: DM B failed to serve the correct portion size of spaghetti noodles, marinara sauce and tossed salad according to the prepared menu for lunch for 50 residents.Dietary Aide C failed to follow the recipe for meat marinara sauce, causing them to run out of meat marinara sauce before they finished serving the lunch meal on 01/07/2026, and 9 residents did not receive meat marinara sauce. These failures could affect residents who received food from the kitchen by contributing to dissatisfaction, poor intake, and/or weight loss.The findings include:During an observation on 01/07/2026 between 12:13 PM- 1:01 PM, DM B served the lunch meal and served spaghetti noodles with a plastic pasta utensil, tossed salad with plastic tongs and plain marinara sauce after running out of meat marinara sauce with a rubber spoon. These utensils did not have a serving size on them.During an observation on 01/07/2026 at…

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 information to resident's and their representatives on their rights related to filing grievances or concerns for 16 of 21 confidential residents. The facility failed to ensure 16 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, access to Grievance forms, information regarding who the facility Grievance officer was with their contact information, and accommodations to file an anonymous Grievance. This failure could place the residents at risk of unresolved Grievances and decreased quality of life. Findings include: During a confidential interview on 05/12/2025 at 10:00 AM with the resident council, 16 confidential residents stated they did not know how to file a formal Grievance. Residents attending Resident Council stated they did not have access to Grievance forms, and they did not know where Grievance forms were kept. Additionally, residents in Resident Council were not aware of who their Grievance Officer was, nor the process to resolve…

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 review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 16 residents (Resident #40) reviewed for advance directives. The facility failed to ensure Resident #40's Out of Hospital Do Not Resuscitate (OOHR) form was signed and dated by the resident's physician and included the physician's license number. The facility failed to ensure Resident #40's OOH DNR contained accurate dates from Resident #40's Legal Guardian and the two witnesses. This failure could place residents at risk for not having their end of life wishes honored and having incomplete records. Findings included: Record review of the face sheet, dated 05/13/2025, revealed Resident #40 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Paraplegia (type of paralysis that results in partial or complete loss of movement and sensation in the legs and lower part of the body), Schizoaffective disorder, bipolar type…

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 that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #36) reviewed for supervision, 1. The facility failed to provide effective monitoring and interventions to reduce Resident #36's wandering which was intrusive to other residents' privacy and unsafe for Resident #36 and other residents 2. The facility failed to keep the administrative offices closed and not accessible to the residents when no staff were present. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals. The findings include: Record review of Resident #36's admission record, dated 05/12/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (memory loss and…

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 1 of 6 residents (Residents #39) reviewed for infection control. 1. CNA A failed to change her gloves and utilize hand hygiene during incontinence care with Resident #39. These failures could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #39's undated face sheet revealed a [AGE] year-old female originally admitted to the facility 11/5/2024. Resident #39 had a medical history of hypertension (high blood pressure), depression, and cerebral infarction (a condition where brain tissue dies due to a lack of blood flow, causing necrosis in the brain). Record review of Resident #39 of annual MDS dated [DATE] Section H- Bladder and bowel revealed Resident…

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 observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 31 of 31 residents reviewed for infection control (Residents #1- #31). 1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination from residents (Resident #3, #4, #6, and #28) positive with COVID-19. 2. The facility failed to place readily visible signage on the door of Resident #1-#30 who was actively on contact precautions. 3. The DM and CNA A entered the room of a resident (Resident #6 and #28) who was on transmission-based precautions without proper PPE. 4. Housekeeper D entered the room of a resident (Resident #14 and #19) who was on transmission-based precautions without proper PPE. 5. The HA entered the room of a resident (Resident #30)…

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, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 2 of 17 residents (Residents #23, and #47) reviewed for transfers, in that: The facility did not provide Resident #23 and Resident #47 with a written bed-hold policy when the residents were transferred out to the hospital or were on therapeutic leave. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions. The findings were: Record review of Resident #23's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include…

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 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. The facility failed to protect foods from potential contamination. Foods were not handled in a manner to prevent contamination. Food contact equipment and other equipment was not maintained in a clean manner. Foods were not stored according to manufacturer's recommendation. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation on 03/26/24 at 09:34 AM, revealed concord grape jelly, dated 02/26/24, was on the dry pantry shelf. More than 75% of the jelly was gone. The label on the back of the jar reflected, Refrigerate after opening. Observation on 03/26/24 at 9:41 AM, revealed unlabeled and undated pancakes and toast in the microwave. Observation on 03/26/24 at 09:25 AM, revealed opened box coffee concentrate 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.

Based on observation , interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. The facility failed to ensure that the kitchen oven was maintained in safe operating condition. The facility failed to ensure that the kitchen coffee machine was maintained in safe operating condition. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies. The findings included: Observation on 03/26/24, at 09:25 AM, revealed the door to the coffee machine ajar and unable to close. Observation on 03/26/24, at 12:35 PM, revealed two pieces of folded cardboard in the left and the right doors of the oven. Observation on 03/26/24, at 12:36 PM, revealed the Food Service Manager retrieving the pureed food items from the oven and placing them on the right side of the steam table, not utilizing the middle of the steam table. During an interview on…

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, observations and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 7 of 17 residents (Residents #12, #14, #23, #28, #40, #44 and #47) reviewed for care plans as follows: Resident #12 did not have a care plan for urinary incontinence. Resident #14 did not have a care plan for urinary incontinence. Resident #23 did not have a care plan for urinary incontinence. Resident #28 did not have a care plan for urinary and dehydration. Resident #40 did not have a care plan for cognitive loss, vision, communication, urinary incontinence, and dental care. Resident #44 did not have a care plan for falls. Resident #47 did not have a care plan for cognitive loss. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include : Record review of Resident #12's face sheet, dated 03/26/24, revealed a [AGE] year-old-male was admitted to 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 control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 4 of 6 (Residents #1, #31, #38 and #45) and 2 of 2 (CNA C and CNA D) and 1 of 1 (LVN A) staff reviewed for infection control. 1. CNA C failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #45. 2. CNA D failed to perform hand hygiene between glove changes and used disposal wipe multiple times when providing incontinent care for Resident #1. 3. LVN A failed to clean surface before placing wound supplies on surface while providing wound care to Resident #31 and Resident #38. These failures could place residents at risk for spread of infection and cross contamination. Findings include: 1. Resident #1 Record review Resident #1's face sheet dated 03/27/24 reflected a [AGE] year-old female who 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 observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 1 treatment cart observed for drug storage. The facility failed to ensure LVN B did not leave wound cleanser on top of the treatment cart unsupervised. This failure could place residents at risk of harm due to misuse or accidental ingestion. ,. The findings were: Record review Resident #12's face sheet dated 03/26/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stroke, diabetes (high blood sugar), dementia (cognitive loss), hypertension (high blood pressure), and major depressive disorder (mental illness, feeling of sadness). Record review of Resident #12's quarterly MDS assessment, dated 02/20/24 revealed a BIMS score of 13, which indicated cognition was intact. Section M - skin conditions reflected Resident…

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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 8 of 16 residents. The facility failed to: 1. Engage in activities at scheduled times. 2. Engaging activity replacement for scheduled activities that were cancelled or not completed. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings include: Observations on 2/26/2023, the AD was in the building, Surveyor was in the building from 11:00am-4:00pm, Bingo was held in the dining hall at 2:00pm, there were no other activities occurring throughout the hours of 11:00am-4:00pm. Observations of resident rooms on 2/26/2023 at 12:30pm revealed no activity calendars displayed in any 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.