Cuero Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 28, 2024

  47564 Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #3) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 1/26/2024. The noncompliance was identified as PNC. The IJ began on 1/26/2024 and ended on 1/26/2024. The facility had corrected the noncompliance before the survey began. 2. Nurse Aide-E transferred Resident #3 from the bed to the resident's wheelchair using a gait belt by herself and lower the resident to the floor on 02/04/2024. […]

• Immediate jeopardy, isolatedF805Sep 28, 2024

  Based on interviews and record reviews, the facility failed to ensure residents received food provided and prepared in a from designated to meet individual needs for 1 of 3 residents (Resident #2). The facility failed to ensure Resident #2 received the correct diet texture to prevent a choking hazard when Resident #2 was served a regular texture diet despite being prescribed a pureed texture diet. This failure to follow dietary orders could place residents at risk of harm, serious injury, or death. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. […]

• Immediate jeopardy, isolatedF760Apr 6, 2023

  Based on interview and record reviews the facility failed to ensure residents were free of significant medication errors for 1 of 11 residents (Resident #1) reviewed for significant medication errors. The facility staff failed to continue Resident #1's anticoagulant (Anticoagulants are a group of medications that decrease your blood's ability to clot) medication when she returned from the hospital after being gone less than 24 hours. The Resident missed 9 days of her anticoagulant medication which required treatment in a hospital for bilateral embolism (A pulmonary embolism is a clot in the veins of one or both lungs.) The noncompliance was identified as PNC(past non compliance). The IJ (immediate Jeopardy) began on 12/1/2022 and ended on 12/09/2022. […]

• Immediate jeopardy, isolatedF580Jul 1, 2022

  Based on observation, interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 6 Residents (Resident #1) whose records were reviewed. LVN B failed to contact MD when Resident #1 had a change of condition (infection) to the left great toe on 06/26/22 . LVN C failed to contact MD when Resident #1 had a change of condition (infection) to the left great toe on 06/26/22 . […]

• Immediate jeopardy, isolatedF684Jul 1, 2022

  Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that: Facility staff failed to provide Resident #1 with a complete admission head to toe skin assessment and failed to notify the MD six days after the admission that the resident's left great toe had a change of condition. Eight days after admission, the resident's left great toe was amputated on an emergency basis, at a local hospital, because of an infection to the left great toe This failure resulted in the identification of an IJ (Immediate Jeopardy) on 06/29/22. […]