Nocona Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF700May 22, 2023

  Based on observations, interviews, and record reviews the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation or physician's orders for 1 (Resident #1) of 12 residents reviewed for bed rails in that: The facility failed to assess Resident #1 for entrapment from bed rails or contact Resident #1's representative to obtain informed consent, assess risk for entrapment or physician's orders. Resident #1 lodged (entrapped) his left arm on 12/28/22 into the 1/2 sized bed rail, causing him to sustain bruising to his chest, and psychosocial harm. An IJ (Immediate Jeopardy) was identified on (05/19/2023). […]

• Actual harm, isolatedF755Aug 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure the acquiring and administering of all drugs and biologicals to meet the needs of 1 of 6 residents (Resident #9) whose records were reviewed for medication orders. The facility failed to ensure Resident #9 [MEDICATION(S)] ointment 0.3% ([MEDICATION(S)]) for [CONDITION(S)] was available for administration as ordered by the physician. This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection. The findings include: Review of Resident #9's Admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. […]

• Actual harm, isolatedF760Aug 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure freedom from a significant medication error for 1 of 6 residents (Resident #9) whose records were reviewed for medication orders. The facility failed to ensure Resident #9's [MEDICATION(S)] ointment 0.3% ([MEDICATION(S)]) for [CONDITION(S)] was administered as ordered by the physician. This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection. The findings include: Review of Resident #9's Admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  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 one of one kitchen, in that: The facility failed to store nonperishable dry foods in the kitchen that were sealed and/or labeled with open date.The facility failed to store foods in the refrigerator that were labeled with an identifier and/or open date.The facility failed to discard expired or spoiled foods. These failures could place residents at risk for decline in nutritional health status and foodborne illness. […]

• No harm, potential for more than minimal, widespreadF851Feb 13, 2026

  Based on interview and record review, the facility failed to electronically submit to Center for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 Fiscal Year (FY) quarters reviewed. FY Quarter 4 2025 (July 1 - September 30) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 4 2025 (July 1 - September 30). […]