Cordell Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cordell Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Sep 5, 2025

  Based on observation and interview, the facility failed to ensure:a. showers were cleaned between each use, andb. the walls of residents' rooms were not damaged during 2 of 2 observations made for a clean, sanitary, and home like environment.The administrator identified 53 residents resided in the facility.Findings:1. On 09/04/25 at 9:40 a.m., Resident #52's room was observed to have two areas 6 inches by 18 inches of damaged sheetrock and missing paint on the wall where the bed was against the wall. Resident #52 quarterly assessment, dated 07/10/25, showed their cognition was intact with a BIMS score of 15. The assessment showed Resident #52 was dependent for transfers. […]

• No harm, potential for more than minimal, patternF868Sep 5, 2025

  Based on record review and interview, the facility failed to have an effective quality assessment and assurance program that identified concerns and implemented actions to correct the concerns. The DON identified 53 residents resided in the facility. An undated policy provided by the facility titled Quality Assurance and Performance Improvement Program, read in part, The primary purpose of the Quality Assurance and Performance Improvement program is to establish data-driven, facility-wide processes that improve quality of care.On 09/05/25 at 11:55 a.m., the administrator was asked for quality assurance and performance improvement meeting documentation for the past year, from August 2024 thru August 2025.The administrator stated they did not have a book, or any documentation, for that time… […]

• No harm, potential for more than minimal, patternF686Apr 25, 2024

  Based on observation, record review, and interview, the facility failed to ensure an antibiotic for a wound was justified and a wound culture had been obtained for one (#2) of two sampled residents reviewed for wounds. The Administrator identified 51 residents resided in the facility. The Resident Matrix, dated 04/22/24, documented two residents with wounds. Findings: An undated Antibiotic Stewardship-Review and surveillance of Antibiotic Use and Outcomes policy, read in part .The IP, or designees, will review all antibiotics starts within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified .Therapy is not justified if .The organism is not susceptible to antibiotic chosen .Therapy was started awaiting culture, but no organism was… […]

• No harm, potential for more than minimal, patternF730Apr 25, 2024

  Based on record review and interview the facility failed to ensure annual competency reviews were completed for two (CNA #2 and CNA #3) of three sampled staff reviewed for annual competency skills checks. The Administrator identified 52 residents resided in the facility. Findings: CNA #2's date of hire was 10/21/21. The personnel file did not contain documentation an annual competency review had been completed. CNA #3 date of hire was 09/21/20. The personnel file did not contain documentation an annual competency review had been completed. On 04/25/24 at 2:21 p.m., the Administrator was asked if there were any annual competency reviews for CNA #2 and CNA #3. They reviewed the personnel files and stated there was not any documentation of competency reviews. […]

• No harm, potential for more than minimal, patternF812Apr 25, 2024

  Based on observation, record review and interview, the facility failed to ensure food was labeled, dated, and not kept beyond the Use by Date. The Administrator identified 52 residents resided in the facility. The DON identified 50 residents who received nutrition from the kitchen. Findings: A Dietary Services Food Storage policy, revised 01/20/14, read in part .Leftovers that are potentially hazardous foods shall be used, or disposed of, within 24 hours. Non-potentially hazardous leftovers that have been heated or cooked may be refrigerated for up to forty-eight (48) hours .All food is dated as to time received or cooked to ensure timely us (sic) and/or disposal . On 04/22/24 at 3:17 p.m., a brief initial kitchen observation was completed with [NAME] #1. […]