Mineral Wells Nursing & Rehabilitation

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure the temperature of the banana pudding was taken prior to leaving the kitchen. The facility failed to ensure that staff performed hand hygiene while preparing food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 04/15/2025 between 11:00 AM and 12:30 PM the cook failed to take the temperature of the banana pudding, prior to resident's lunch trays being plated, placed on cart and ready to leave the kitchen. [NAME] F stated she had forgotten to take the temperature of the banana pudding. [NAME] F stated the banana pudding should have had temperature taken prior to food being plated. The AD failed to perform hand hygiene, when she entered the kitchen, before she grabbed a can of tomato juice and an empty container. The AD…

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 provide services with reasonable accommodation of needs for 1 of 10 (Resident #9) residents reviewed forreasonable accommodation of needs The facility failed to provide a working communication system on 04/15/2025 that was easily at reach and that would allow Resident #9 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #9's face sheet dated 04/17/2025, revealed: an [AGE] year-old-female admitted on [DATE] with a recent readmission on [DATE]. Resident #9 had the following diagnosis Dementia, anxiety disorder, Type 2 Diabetes, and respiratory failure. Record review of Resident #9's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns: Resident #9 had a BIMS score of 5, meaning severe cognitive impairment; Section GG-…

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 at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #47) of 32 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to obtain physician's order prior to placing Resident #47's knee immobilizer to her right leg. This failure could place residents at risk of not having a physician order followed. Findings include: Record review of Resident #47's electronic face sheet dated 04/17/2025 revealed an [AGE] year-old female admitted on [DATE]. Resident #47's diagnosis included Unspecified Fracture of Right Patella (kneecap), Hypertension (high blood pressure), Type 2 Diabetes Mellitus, Unspecified Dementia, Muscle Weakness (generalized) Record review of Resident #47's physician orders revealed an admission date of 03/27/2025, and further review revealed no evidence of an order for a knee immobilizer. Record review…

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 residents were free from misappropriation of property for one (Resident #7) of 5 residents reviewed for misappropriation of property. The facility failed to ensure Resident #7 was free from misappropriation of property when AP borrowed money for personal benefit. The non-compliance was identified as past non-compliance dated 1/24/25. The facility had corrected the noncompliance on 1/28/25 before the survey began. This failure could place residents at risk of exploitation/misappropriation of property and financial distress. Findings include: Record review of Resident#7's face sheet dated 3/5/25 revealed [AGE] year-old male, with an original admission date 7/21/23 and a re-admission date of 11/10/23. Resident #7 Diagnoses include Traumatic subarachnoid hemorrhage with loss of consciousness (brain injury), depression, anxiety, apraxia (motor disorder caused by brain), hemiplegia affecting left side (paralysis on one side). Record 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 observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure 5 pies were covered when being stored in the refrigerator. This failure could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/25/2024 between at 8:30 AM to 9:00 a.m. of the kitchen's refrigerator revealed: Two metal trays with 5 pies sitting on them uncovered surrounded by food. Above the uncovered pies were boxes and plastic containers with liquid food. Three kitchen staff were present in the kitchen that did not include the DM. During an interview on 02/25/2024 at 8:43 a.m., the DA stated she was unsure if pies stored in the refrigerator needed to be covered. She stated that the pies had been cooked and placed in the refrigerator on the night of 02/24/2024. During an interview on 02/26/2024 at 10:10 a.m., the DM stated…

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, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 (Resident #4) residents reviewed for pressure ulcers. The facility failed to provide care as ordered to bilateral heel pressure ulcers. The facility failed to assess pressure ulcers weekly. The facility failed to provide interventions to prevent development or worsening of Resident #4's heel pressure ulcers. These failures could place residents at risk of infections and worsening of wounds. Findings include: Record review of Resident #4's electronic face sheet dated 02/27/2024 revealed an [AGE]…

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 reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for oxygen administration. The facility failed to place nebulizer mask and tubing in a bag and date when replaced. The facility failed to obtain physician's order prior to supplying oxygen to resident. The facility failed to monitor oxygen concentrator tubing connected appropriately. The facility failed to date humidifier on oxygen concentrator when replaced. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident #5's electronic face sheet dated 02/27/2024 revealed a [AGE] year-old female who was admitted to the facility most recently on 11/10/2023 with diagnoses that included: dementia, gastrointestinal hemorrhage (stomach bleed), heart failure (heart disease…

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 one (Resident #1) of two residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 11/15/23, revealed a 76- year- old female admitted to the facility on [DATE] with diagnoses including senile degeneration of brain and morbid obesity. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was frequently incontinent of bladder and always of bowel.…

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 reviews, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for food service. The facility failed to label items in refrigerators with an identifier of the food item. The facility failed to discard items in refrigerators after 7 days. The facility failed to seal items in refrigerators and dry food storage room. These failures placed all residents at risk of food borne illnesses. Findings included: During an observation and interviews on 12/18/22 at 10:06 AM Refrigerator #2 30 individual serving dishes with foil covering with a date of 12/15. There was no label on the dishes to identify the contents. [NAME] said they were a Chili cornbread pot pie. She said the person that prepared them should have put a label on them to identify the food item before storing them in the refrigerator. 1 clear tub of mixed salad greens with a date of 12/8. The container was open, and [NAME] said that it should have been a closed container and that…

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 that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #52) of 2 residents reviewed for dialysis. The facility failed to ensure Resident #52 had orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of: infection or bleeding, edema, blood pressure, or fluid overload. This failure could place the resident who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Review of Resident #52's electronic face sheet, accessed 12/18/22, revealed the resident was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnosis that included chronic kidney disease stage 4 (a medical condition in which a person's kidneys cease functioning on 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.