Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Lamesa during CMS and state inspections, most recent first.
A CNA did not sanitize hands between glove changes during incontinent care for one resident, and two LPNs failed to wear gowns during wound care and assisting with high-contact care for two residents on EBP. The residents had pressure-related wounds and orders for daily wound care, and the facility’s EBP signage and PPE cart were present at the bedside.
A resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and tobacco use, was observed smoking without the required smoking apron during a supervised smoke break. His physician order required the apron on all smoke breaks, and the care plan and smoking assessment identified direct supervision and apron use. Staff interviews showed confusion about the requirement, and one staff member allowed the resident to smoke even when he refused the apron.
Improper Storage of Oxygen Tubing: A resident with chronic respiratory failure, severe cognitive impairment, and an O2 order had oxygen tubing and a nasal cannula observed on the floor near the bed on two separate observations. The ADM and DON stated tubing should be stored in a labeled plastic bag when not in use, and the facility policy required PRN oxygen cannula and tubing to be kept in a plastic bag off the floor.
An Overstock Medication Cart and a Treatment Cart were observed unlocked and unattended near the nurse's station, with drawers open and medications, creams, ointments, and supplies visible. An LVN stated she was transferring medications from the Overstock Medication Cart and was unaware it had been left unlocked, while staff confirmed both carts were supposed to be locked whenever unattended. The facility policy stated medication carts must be securely locked when out of the nurse's view.
Unlabeled Food Stored in Refrigerator: Surveyors observed a bowl of yogurt and a bowl of cranberry sauce in Kitchen A’s refrigerator without labels. The DS stated the items were not labeled when placed in the refrigerator and confirmed that all refrigerated food should be labeled and dated. The ADM also stated all food in the refrigerator should be labeled and dated, and the facility policy required refrigerated food to be dated, labeled, and sealed.
A resident with dementia, severe cognitive impairment, history of falls, and independent ambulation was fitted with a Wander Guard device shortly after admission due to adjustment issues and safety concerns, based on a verbal order from an FNP and agreement from family after initial hesitation. However, the DON did not update the comprehensive care plan to include the Wander Guard order or communicate it to the MDS coordinator, and the care plan contained no measurable objectives or timeframes related to wander-management. Staff, including an LVN, confirmed the device was in use and that such devices are normally included in care plans used by all direct care staff, while facility policies required a specific plan of care for wanderers and implementation of practitioner orders in the comprehensive care plan.
During a lunch meal, dietary staff failed to follow standardized recipes and prescribed portion sizes, resulting in incorrect servings of spaghetti, salad, and marinara sauce, and leaving several residents without the planned meat marinara sauce. The dietary manager used unmarked utensils and admitted not knowing the actual portion sizes served, while the dietary aide who prepared the meat sauce acknowledged he did not use the facility’s recipe and instead cooked it as he would at home. Facility documents showed specific required portions and a standardized recipe for meat marinara sauce, as well as policies mandating adherence to standardized recipes and cooking instructions, but these were not followed during the meal in question.
A long-term care facility failed to maintain an effective infection control program, with staff entering rooms of COVID-19 positive residents without proper PPE and lacking visible signage for contact precautions. Additionally, improper cohorting of residents increased the risk of cross-contamination.
Hand Hygiene and EBP PPE Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. During incontinent care for one resident who was frequently incontinent of bowel and bladder and required substantial to maximal assistance with toileting hygiene, a CNA removed soiled briefs, changed gloves, and placed a clean brief on the resident but did not sanitize hands between the glove changes. Two residents were on Enhanced Barrier Precautions and had wound care orders for pressure-related wounds. One resident had diagnoses including stroke, right above-knee amputation, hypertension, and generalized muscle weakness, and had an unstageable pressure ulcer and a care plan directing daily wound care. Another resident had diagnoses including CHF, COPD, dementia, and muscle wasting, and had a Kennedy ulcer with daily wound care ordered. During wound care observations, one LVN performed wound care to the first resident’s coccyx wound without wearing a gown, and another LVN assisted with turning the resident and handling linens and pillows without wearing a gown. During wound care for the second resident, one LVN wore gloves and a gown while performing wound care, but the assisting LVN wore gloves only and did not wear a gown while helping turn the resident and replace pillows and linens. The report states that Enhanced Barrier Precaution signage and PPE carts were present at the bedsides of the two residents on EBP. In interviews, the LVNs stated they should have worn gowns during wound care and assisting with high-contact activities, and the CNA stated she forgot to sanitize her hands between glove changes during incontinent care. The ADM and DON stated nursing administration was responsible for ensuring hand hygiene and EBP protocol were followed, and both acknowledged that proper PPE and hand hygiene were expected during resident care.
Failure to Ensure Required Smoking Apron Use During Supervised Smoke Break
Penalty
Summary
The facility failed to ensure that Resident #51 received adequate supervision and use of an assistance device during smoking to prevent accidents. Resident #51 was a male resident admitted on [DATE] with diagnoses including anxiety, hypertensive retinopathy, vascular dementia with behavioral disturbance, intermittent explosive disorder, weakness, muscle wasting and atrophy, and lack of coordination. His MDS assessment completed on 1/9/26 showed a BIMS score of 7, indicating severe cognitive impairment, and the assessment also indicated that he used tobacco. The resident’s physician active orders dated 7/27/26 included an order dated 6/18/26 that a smoking apron was to be used on all smoke breaks. His care plan identified that he smoked and included interventions that he would keep lighters and matches with staff, participate in supervised smoke breaks, and wear a smoking apron while smoking. His Safe Smoking Assessment dated 7/12/26 stated that he required direct supervision while smoking and that all smoking materials would be kept at the nurse’s station. During observation on 7/27/26 at 11:00 a.m., Resident #51 was seen outside smoking with other residents. Staff passed out smoking materials, lit cigarettes, and supervised the smoke break, but Resident #51 was observed smoking without a smoking apron. Interviews with staff showed that one staff member knew he was supposed to wear an apron but allowed him to smoke when he refused, while another staff member stated she was not aware he was required to wear one and had only given the apron to another resident. The resident stated he did not wear a smoking apron and was willing to wear one. The DON and ADM stated they were not aware he was not wearing the apron as required and that staff were expected to follow physician orders and ensure residents wore smoking aprons when indicated.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to ensure that Resident #58 received safe and appropriate respiratory care when oxygen tubing and a nasal cannula were observed on the floor near the resident’s bed during an initial tour observation and again during a later observation. Resident #58 was a female admitted on 07/22/17 with diagnoses including cerebral infarction, chronic respiratory failure, and cognitive communication deficit. Her quarterly MDS reflected a BIMS score of 00, indicating severe cognitive impairment, and her care plan noted dyspnea and chest pain related to cardiac insufficiency, with an intervention to apply O2 for complaints of chest pain as ordered. The resident had a physician order allowing O2 at 2L-4L to maintain O2 saturation at 90 and above. Nursing progress notes documented that the resident had a low O2 saturation of 87% on room air, hospice was notified, and oxygen was used via nasal cannula. During interviews, the ADM and DON stated they were not aware the oxygen tubing was not being properly stored while not in use and stated it should be kept in a labeled plastic bag and off the floor. The facility policy titled Oxygen Therapy stated that oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use.
Unlocked Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments for 2 of 5 medication carts observed for storage: the Overstock Medication Cart and the Treatment Cart. During an observation, both carts were found next to the nurse's station with the locks popped out and no staff present. The nurse's station was in a high-traffic area, and residents, staff, and visitors were observed in and around the area while the carts were unattended. The Overstock Medication Cart had all drawers opened, with various blister packs of pills, bottles of medications, and medical supplies visible inside. The drawer containing narcotic medications was open, although the lock box inside that drawer remained secure. The Treatment Cart also had all drawers opened, with creams, ointments, gels, iodine, gloves, bandages, and gauze visible. The drawer containing the internal lock box was locked. LVN F stated she was responsible for the Overstock Medication Cart, was transferring medications from it to the Medication Aide cart, and was unaware she had left it unlocked. She also stated all carts containing medications must be locked when unattended. LVN B stated neither cart was assigned to anyone in particular, that nurses had keys to the Treatment Cart, and that both carts had to be locked while unattended. She stated she was not aware both carts were unlocked and unattended. The ADM and DON stated medication carts and treatment carts should be locked anytime they were unattended, and the facility policy stated medication carts must be securely locked at all times when out of the nurse's view and locked when not being used.
Unlabeled Food Stored in Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in Kitchen A. During an initial kitchen tour on 07/26/2026, surveyors observed a bowl of white pudding with no label and a bowl of red sauce with no label in the refrigerator. During an interview later that day, the DS identified the white pudding as yogurt and the red sauce as cranberry sauce and stated the bowls were not labeled when placed in the refrigerator. He stated that all items should be labeled when placed in the refrigerator. During subsequent interviews, the DS stated all food in the refrigerator should be labeled and dated and that all dietary staff were trained in proper food storage. He stated he was not aware the bowl was not labeled and that he checked refrigerators three times a week on Monday, Wednesday, and Friday, while his Assistant Manager checked them on Tuesday and Thursday. The ADM also stated all food in the refrigerator should be labeled and dated, that staff were trained in proper food storage, and that she was not aware food was being stored without a label. Record review of the facility policy titled Food Labeling and Dating, revised 1/2018, stated refrigerated food should be dated, labeled, and sealed.
Failure to Care Plan Use of Wander Guard Device for Cognitively Impaired Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident who was using a Wander Guard electronic signaling device. The resident was an elderly male admitted with dementia without psychosis, history of falling, unsteadiness on feet, and weakness, and had a BIMS score of 05 indicating severe cognitive impairment. Review of the resident’s comprehensive care plan, last reviewed in late March, showed no care plan addressing the use of the Wander Guard device, despite its use for wander-management. Interviews revealed that the Wander Guard device was placed on the resident within a week or two after admission due to his being new to the facility, independently ambulatory, and not looking like a resident, and later due to increased agitation when he realized his placement was not short-term. The ADM stated the device was placed for the resident’s protection so visitors would not mistakenly allow him to leave. The DON and the FNP both reported that the FNP had given a verbal order for the Wander Guard during the resident’s adjustment phase, related to his dementia and independent ambulation, although neither recalled the exact date. The family member confirmed they were consulted about the need for a wander-management device at admission, initially declined, but later agreed after the resident did not adjust to placement, and they were aware the device was in place. Nursing staff and leadership confirmed that the Wander Guard device was in use but not reflected in the care plan. An LVN stated the resident wore the device on his ankle and believed it was placed about a week after admission, and that wander-management devices were usually part of the care plan so staff would know they should be in place. The DON acknowledged she took the verbal order for the device, failed to add it to the care plan, and did not communicate the order to the MDS coordinator, who typically updated care plans based on practitioner orders and information from stand-up meetings. Both the DON and ADM stated that the care plan is used by all direct care staff to know residents’ specific care needs, and the DON and ADM each stated that a potential negative outcome of not updating the care plan to include the Wander Guard was that staff might not know the resident was supposed to have the device on. Facility policies on signaling devices and comprehensive care plans required that a plan of care be developed and implemented with specific approaches and goals for wanderers and that the interdisciplinary team review practitioner orders and implement a comprehensive care plan, which was not done in this case.
Failure to Follow Standardized Recipes and Portion Sizes for Lunch Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus and standardized recipes were followed and correct portion sizes were served during a lunch meal. On the reviewed lunch service, the dietary manager serving the meal used a plastic pasta utensil for spaghetti noodles, plastic tongs for tossed salad, and a rubber spoon for marinara sauce, none of which had marked serving sizes. The dietary manager stated she did not know the portion sizes of any of these utensils and acknowledged that the salad portions she served were barely a full serving or probably less than a serving. She reported that she assumed she was giving correct portion sizes despite the lack of portion markings and that she did not prepare the food for the meal herself. During the same lunch meal, the kitchen ran out of meat marinara sauce before all residents were served, and 9 residents received only plain marinara sauce instead of meat marinara sauce. Observation of the pantry showed one can of marinara sauce labeled as containing 105 ounces. The facility’s diet spreadsheet indicated that residents should receive a #8 scoop (½ cup) of spaghetti noodles, a 6‑oz ladle (¾ cup) of meat marinara sauce, and two #8 scoops (1 cup) of tossed salad. The facility’s standardized recipe for Marinara Meat Sauce specified a suggested portion of a 6‑oz ladle for 50 servings, using 9 lbs of ground beef and one gallon plus 2⅜ quarts of marinara sauce. The dietary aide who prepared the meat marinara sauce stated he cooked a whole 10‑lb roll of meat and used one can of marinara sauce, and admitted he did not follow the facility recipe, instead preparing the sauce as he would at home. He acknowledged that sometimes recipes are used and sometimes they are not. Facility policies titled “Adherence to Standardized Recipes” and “Preparation of Foods” required that all meals be prepared in accordance with approved standardized recipes, that recipes not be altered without approval, and that recipes and cooking instructions be followed. Despite these policies and the dietary manager’s documented completion of food handler and food manager training, the meal was not prepared or portioned according to the facility’s standardized recipes and portion guidelines, resulting in incorrect portions and some residents not receiving the planned meat marinara sauce.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with contact precautions and improper use of personal protective equipment (PPE). Staff members, including a dietary manager, certified nursing assistants, housekeepers, and healthcare aides, entered the rooms of residents who were on transmission-based precautions without wearing the appropriate PPE. This failure was observed in several cases, including residents who tested positive for COVID-19, thereby increasing the risk of cross-contamination and the spread of infection. Additionally, the facility did not place visible signage on the doors of residents who were on contact precautions, which is a critical step in alerting staff and visitors to the necessary precautions required to prevent the spread of infection. This oversight was noted for residents who were actively on contact precautions, further compromising the facility's infection control measures. The facility also failed to appropriately cohort residents, as evidenced by the placement of a resident who was not positive for COVID-19 with a resident who was confirmed positive. This improper cohorting could lead to unnecessary exposure and transmission of the virus among residents. The report highlights these deficiencies, which could place all residents at risk for the spread of infection and cross-contamination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Lamesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brownfield Rehabilitation And Care Center | 34.5 mi | ★★★★★ | 0 | 0 |
| Apex Secure Care Brownfield | 34.6 mi | ★★★★★ | 18 | 1 |
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