Palo Pinto Nursing Center

In the surveyor’s words

From the most serious findings on record at Palo Pinto Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF656Aug 25, 2024

  49427 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 2 (Resident #9 and #24) of 24 residents reviewed for care plans. 1. The facility failed to develop and implement a comprehensive care plan for Resident #24 to address the left femur fracture sustained on [DATE] and current transfer status. 2. The facility failed to update Resident #24's Kardex (a brief digital overview of the resident's needs) to reflect she required 2 people to transfer her. As a result, the resident was transferred on [DATE] by a hospitality aide. Resident #24 was sent to the hospital and sustained a femur fracture. 3. […]

• Immediate jeopardy, isolatedF689Aug 25, 2024

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision/assistance to prevent accidents for one (Resident #24) of four residents reviewed for accidents. The facility failed to ensure Resident #24 was free of accident hazard when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2024

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for three of four dietary staff (Dietary Aide Y, Dietary Aide Z and Dietary Manager) and the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the low temperature dish machine was working properly on 08/20/24 to ensure appropriate chlorine sanitizer ppm levels. 2. The facility failed to ensure the Dietary Aide Y, Dietary Aide Z and the Dietary Manager wore an effective hair restraint during the lunch meal preparation on 08/20/24. 3. […]

• No harm, potential for more than minimal, widespreadF925Apr 15, 2022

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and insects. The facility failed to maintain an effective pest control program to address roaches. The facility's failure could affect the residents by placing them at risk for foodborne illness and infectious disease from exposure to contaminants carried by roaches. The findings included: Interview on 04/12/22 at 9:49 AM, Resident #64 was lying in this bed in his room (shared with Resident #5). He complained of roaches in his room. Interview on 04/12/22 at 12:16 PM, Resident #5 was in the hallway and complained of roaches in his room (shared with Resident #64). […]

• No harm, potential for more than minimal, patternF728Apr 10, 2025

  Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 (SNA A and SNA B) of 2 Student Nurse Aides reviewed for nursing services. The facility failed to ensure SNA A and SNA B was certified within the required time. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings include: Review of the facility's employee files revealed: -SNA A had a hire date of 12/08/2021 and worked full time. […]