Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nocona Rehabilitation And Care Center during CMS and state inspections, most recent first.
Surveyors found multiple food storage and sanitation failures in the kitchen, including dry goods that were opened but not sealed or dated, moldy hamburger buns, expired bread, and several refrigerated items that were unlabeled, undated, or past their use-by dates. Staff acknowledged that some items should have been discarded and that temperature logs for coolers and freezers were incomplete, despite policy requiring food to be covered, labeled, dated, and temperatures to be checked and documented each AM and PM shift.
Failure to submit CMS PBJ staffing data: The facility did not electronically submit complete and accurate direct care staffing information for a CMS reporting quarter, including agency and contract staff, based on payroll and other auditable data. Survey review found the PBJ report was not submitted, while interviews showed the new management team was trying to obtain missing records from the prior management company, the DIS could not locate a records-maintenance policy, and the Regional Nurse Consultant said there was no separate PBJ policy beyond the CMS manual.
The facility failed to maintain documentation and evidence of its ongoing QAPI program. Record review showed QAPI meeting minutes were available only from one meeting, with no earlier documentation. The RNC stated the prior management company took the records when it left, and corporate administrative staff did not have facility policies and procedures for maintaining facility records.
Failure to maintain antibiotic stewardship monitoring records: The facility did not provide documentation showing ongoing monitoring of antibiotic use for residents, with tracking available only for recent months and no earlier records available for review. The RNC stated prior records were unavailable after the management takeover because the previous company took them, and corporate administrative staff did not have policies and procedures for maintaining facility records.
The facility failed to maintain required training documentation for multiple staff members, including the DON, RNs, LVN, CNA, Laundry, and Housekeeping staff. Record review showed missing evidence of training in infection control, compliance and ethics, Resident Rights, QAPI, abuse and neglect, communication, Behavioral Health, Fall Prevention, Restraint Reduction, HIV, and Annual 1hr Dementia. Staff interviews indicated some training had been completed under prior management, but the facility could not produce the records, and the BOM and RNC stated the prior company took the files when it left.
Missing Grievance Records and Policies: The facility failed to maintain grievance documentation for the required retention period and could not provide a grievance log or copies of grievances from before the management takeover. The RNC stated the prior management company took the records when it left, multiple emails requesting their return went unanswered, and corporate administrative staff did not have policies and procedures for maintaining facility records.
A resident with dementia, hallucinations, and multiple chronic conditions remained on Seroquel 50 mg HS even after the attending physician approved a dose reduction to 25 mg HS following the consultant pharmacist's GDR review. The order was not noted by licensed nursing staff, the MAR/order summary was not updated, and the medication card still reflected the higher dose; an LVN stated she was unaware of the change and the RN regional clinical support nurse consultant said the DON was expected to note the response and update the order.
The facility did not ensure 8 consecutive hours of RN coverage per day on multiple weekends, as required by policy. Timesheet reviews and staff interviews confirmed that on several occasions, no RN was present for the mandated hours, and the DON acknowledged difficulties in scheduling RNs for weekend shifts.
The facility did not designate a qualified person to serve as director of food service when there was no full-time dietitian, as the Dietary Manager lacked required certification and had not enrolled in certification courses. The contracted dietitian visited only quarterly and was aware of the deficiency, while the administrator also acknowledged the Dietary Manager's uncertified status.
The facility did not maintain the laundry hot water heater in safe working order, resulting in no hot water for laundry operations for about two months. Staff and administration were aware of the issue, and laundry staff used bleach for sanitizing during this period. The deficiency persisted due to delays in obtaining the correct repair parts.
Two residents were found to have damaged window blinds and missing furniture components in their rooms, resulting in an environment that was not well-kept or comfortable. Both residents reported the issues had been present for an extended period, and the facility administrator was unaware of the deficiencies until notified during the survey.
A live lizard was observed in the kitchen above the dishwashing and sink area, and staff interviews confirmed previous sightings of lizards. The facility lacked an active pest control contract, with services discontinued due to non-payment, and no pest control visits had occurred in several months. The facility's policy required pest prevention measures, but these were not effectively implemented.
A resident with severe cognitive impairment, a history of falls, and total dependence on staff was found without access to a working call light system in her room. Observation and interviews confirmed the call light was not operational or within reach, contrary to facility policy and the resident's care plan.
The facility did not pay multiple utility bills for water, gas, and electricity on time, resulting in past due balances and disconnection notices from vendors. The ADM forwarded bills to Accounts Payable and the CEO but was not involved in payment decisions, while the CEO only authorized payments when prompted. Utility vendors reported repeated unsuccessful attempts to collect payment, and some delayed disconnection to avoid impacting residents. The facility's governing board policy assigns responsibility for maintaining a safe environment, but the failure to pay bills demonstrated ineffective resource management.
The facility did not pay essential service vendors, including water and fire services, in a timely manner, resulting in significant past due balances and disconnection notices. Invoices and notices were forwarded to Accounts Payable, but payments were delayed due to the facility's payment process, which required weekly meetings between Accounts Payable and the CEO to determine which bills to pay. The CEO was unaware of the overdue balances until after disconnection notices were issued, and the facility could not provide a policy for vendor payments.
The facility did not maintain RN coverage for at least 8 consecutive hours daily as required, with 17 days lacking RN presence, particularly on weekends. The DON and Administrator confirmed the absence of RN coverage on multiple occasions, and the medical director was aware of the deficiency. Facility policy mandates daily RN coverage, but this standard was not met.
A resident with a history of heart disease, dementia, and osteoarthritis fell and was ordered an x-ray by the physician. The facility failed to provide the x-ray due to unsuccessful attempts to contact the mobile x-ray company. The nurse did not follow up with the physician or inform the DON or the next shift, resulting in the x-ray not being performed, potentially affecting the resident's care.
The facility failed to provide RN coverage for 8 consecutive hours daily for 22 days and lacked a full-time DON for 19 days within a 79-day period. This deficiency, identified through interviews and record reviews, placed residents at risk due to the absence of RN-level care. The facility faced challenges in recruiting staff in a rural area and relied on telehealth services and hospital transfers to manage resident care needs.
The facility failed to maintain food service safety standards, affecting 38 residents. The dishwashing machine lacked a chemical sanitizer, and staff were untrained in its operation. Unsanitary conditions were observed in the kitchen, with soiled equipment and open food items. The absence of a dietary manager and delayed vendor payments contributed to these issues.
A resident with unspecified dementia was not referred for a PASRR re-evaluation after being diagnosed with major depressive disorder and showing potential indicators of psychosis. The facility's MDS coordinator confirmed the absence of a necessary 1012 form, resulting in the resident not receiving PASRR services. This oversight placed the resident at risk of not receiving adequate mental health care.
A resident with mental illness diagnoses, including Bipolar Disorder and Schizophrenia, did not receive a required PASARR Level II evaluation. Despite active diagnoses, the resident's PASARR Level I screening showed no evidence of mental illness, and no PASARR Level II screening or form 1012 was found in the record. The MDS Coordinator and Chief Nursing Officer acknowledged the oversight, which could result in the resident not receiving necessary specialized services.
The facility failed to develop comprehensive care plans within the required timeframe for two residents, leading to a deficiency. One resident with multiple diagnoses had a delayed care plan completion, despite having a baseline plan. Another resident's care plan was only completed after the CNO was notified. The facility's policy requires care plans to be developed within seven days of the comprehensive assessment, which was not followed.
A resident was given Depakote and Ativan without appropriate diagnoses, contrary to facility policy. Interviews with staff confirmed the diagnoses were not suitable for these medications, highlighting a failure to adhere to guidelines requiring specific conditions for antipsychotic use.
The facility failed to implement enhanced barrier precautions (EBP) for three residents with medical conditions requiring such measures. A resident with a gastrostomy tube, another with a stage 4 pressure ulcer, and a third with a PICC line lacked EBP orders, signage, and PPE in their rooms. Staff interviews revealed inconsistent understanding and implementation of EBP, with the CNO acknowledging oversight and lack of leadership.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During the initial kitchen tour, surveyors observed multiple dry storage items on the shelf above the food preparation area that were opened but not sealed or labeled with an open date, including bacon bits, blueberry muffin mix, gravy mix, and creamy wheat. On the bread shelves, surveyors found a package of hamburger buns with blue-green mold affecting all buns, as well as another package of hamburger buns that remained on the shelf past its expiration date. In the first of three refrigerators inspected, surveyors observed several food items that were not properly labeled, dated, sealed, or discarded. These included a bag of scrambled eggs with no label, a container of oranges past expiration, a bag of cooked pork chops with no date or label, a container of gravy dated and marked with a use-by date that had passed, a bag of chopped cooked pork dated and marked with a use-by date that had passed, and a bowl of pudding dated and marked with a use-by date that had passed. Staff stated that some of these items should have been discarded and that one item was leftover scrambled eggs from breakfast that had not been labeled. Surveyors also reviewed the refrigerator and freezer temperature sign-in sheet taped to the outside of refrigerator #1 and found that only the dates from 2/1 through 2/4 had been initialed, while 2/5 through 2/10 were not completed. Staff stated that cooks were responsible for checking and documenting temperatures on the morning and evening shifts but had forgotten to log them. Facility policy required dry storage items to be labeled and dated, refrigerated foods to be tightly sealed and dated, leftovers to be used within 72 hours, moldy bread to be discarded, and cooler and freezer temperatures to be checked and recorded each morning and evening.
Failure to Submit CMS PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 4 2025 (July 1 - September 30), including agency and contract staff, based on payroll and other verifiable and auditable data in the required uniform format. Review of the CMS Payroll Based Journal report showed the facility had not submitted data for that quarter, and the deficiency was identified during survey review of administration records. Record review showed the facility had an employee list dated 2/10/2026 that included an Administrator, 5 RNs, 7 LVNs, 16 CNAs, maintenance, housekeeping, business office, laundry, dietary, therapy, and social work staff. The CMS 802 Matrix dated 2/10/2026 indicated 32 residents in the facility. During interview, the DIS stated the new management group was working with a third-party company to submit payroll reports to CMS, and that she had been trying to obtain information from the previous management company regarding why the quarter 4 2025 payroll information had not been submitted. She also stated the prior administrator removed documentation from the facility, leaving no staffing, training, or other records, and she could not find a policy regarding maintaining records. The VPCS stated her expectation was that CMS PBJ reports be submitted on time and accurately, and the Regional Nurse Consultant stated there was no individual policy for PBJ reporting, only the CMS Electronic Staffing Data Submission Payroll-Based Journal LTC Facility Policy Manual.
Missing QAPI Meeting Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility reviewed for QAPI. Record review showed that the facility had QAPI meeting minutes only from 11/20/2025, and no meeting documentation was available for any earlier dates. During an interview on 02/12/2026, the Regional Nurse Consultant stated she was unable to provide any documentation from before the management takeover on 11/19/2025 because the previous management company took all records when they left. She stated that multiple emails had been sent to the prior company requesting the records, but no response had been received. The QAPI Plan revised 11/19/2025 stated that QAPI meetings were to occur monthly and as needed. During an interview on 02/13/2026, corporate administrative staff did not have facility policies and procedures for maintaining facility records.
Failure to Maintain Antibiotic Stewardship Monitoring Records
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Antibiotic Stewardship program for 1 of 1 facility reviewed for Antibiotic Stewardship. Record review of the antibiotics and infection tracking showed that the facility had tracking available for November 2025, December 2025, and January 2026, but no earlier records were available for review. The facility did not provide documentation of appropriate monitoring of antibiotic use for residents prior to November 2025. During an interview on 02/12/2026 at 10:30 AM, the Regional Nurse Consultant stated she was unable to provide any documentation from dates before the management takeover on 11/19/2025. She stated the previous management company took all records when they left and that multiple emails had been sent requesting the records be returned, without response as of that day. Review of the facility policy titled Antibiotic Stewardship Program, undated, stated the program includes antibiotic use protocols and a system to monitor antibiotic use, including monthly measurement of antibiotic use and tracking at least one outcome measure monthly. During an interview on 02/13/2026 at 3:45 PM, corporate administrative staff did not have facility policies and procedures for maintaining facility records.
Missing Staff Training Documentation
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for new and existing staff members because it could not provide documentation showing required training for 7 of 16 employees reviewed. Record review showed missing evidence of training in infection control for the DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H, along with missing documentation for compliance and ethics for RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H. Additional missing training records included Resident Rights for RN C, RN D, CNA F, and Laundry G; QAPI for RN C, LVN E, CNA F, Laundry G, and Housekeeping H; abuse and neglect for RN C, CNA F, and Laundry G; communication for RN C, CNA F, Laundry G, and Housekeeping H; Behavioral Health for RN C, CNA F, Laundry G, and Housekeeping H; Fall Prevention and Restraint Reduction for the DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H; HIV for RN C, Laundry G, and Housekeeping H; and Annual 1hr Dementia for RN C, LVN E, CNA F, Laundry G, and Housekeeping H. Interviews supported that some staff believed they had completed training under the prior management company, but the facility could not produce the records. CNA F stated she had completed some training when hired and had attended one or two in-services, and Housekeeping H stated she had done more training with the previous company than with the current one. The BOM stated the records available in the conference room were all the personnel records and trainings she had, and the previous management company had taken all records when they left. The RNC stated she could not provide documentation from before the takeover because the prior company took the records, and the President of Clinical Services stated the facility could only provide what it had completed since the takeover. The facility policy titled Orientation Policy stated that documentation supporting completion of orientation shall be maintained in the staff member's personnel file, but corporate administrative staff did not have facility policies and procedures for maintaining facility records.
Missing Grievance Records and Documentation
Penalty
Summary
The facility failed to implement a grievance policy that included maintaining documentation of all grievances for no less than 3 years from the issuance of the grievance decision. During record review, grievance files provided by the AD showed no grievance log tracking or copies of filed grievances prior to 11/19/2025. The facility also did not have documentation and evidence of grievances filed for the previous 3 years. In interviews, the Resident Council stated that since the new management company took over, things seemed to be getting better, especially the answering of call lights, which had been a big issue before. The RNC stated she was unable to provide any documentation from before the takeover on 11/19/2025 because the previous management company took all records when they left. She said multiple emails had been sent to the prior company requesting the records, but no response had been received. Corporate administrative staff also did not have facility policies and procedures for maintaining facility records.
Failure to Update Psychotropic Medication Order After Physician Dose Reduction
Penalty
Summary
The facility failed to act upon the consultant pharmacist's medication regimen review report for one resident who was reviewed for unnecessary medications. Resident #7 had diagnoses including non-Hodgkin lymphoma, type 2 diabetes mellitus, dementia, hypertension, atrial fibrillation, hyperlipidemia, Parkinsonism, left femur fracture, hallucinations, and insomnia. The resident had an order for Seroquel 50 mg by mouth at bedtime for hallucinations. The consultant pharmacist completed a psychotropic gradual dose reduction review and documented a recommendation to evaluate the Seroquel 50 mg at bedtime and consider a dose reduction. The resident's attending physician signed the response section and selected that a dose reduction was appropriate, writing a new order for Seroquel 25 mg at bedtime. The physician also indicated that other causes for symptoms had been ruled out, symptoms were persistent enough to warrant continuation, non-pharmacological interventions were considered, the medication was clinically indicated, and the benefit justified the potential risks. There was no documented evidence that the physician's order had been noted by the DON or other licensed nursing staff, and the order was not changed on the resident's order summary. During observation, the resident's medication card was still labeled Seroquel 50 mg at bedtime. An LVN stated she did not know the physician had written an order to decrease the dose and said the resident may not have agreed to the reduction. The RN regional clinical support nurse consultant stated the expectation was that the DON would note the physician's response and make the order change or give it to the charge nurse to make the change.
Failure to Provide Required RN Coverage on Weekends
Penalty
Summary
The facility failed to provide the required 8 consecutive hours of registered nurse (RN) coverage per day, seven days a week, for 13 out of 104 days during the months of July, August, September, and part of October 2025. Record review of timesheets revealed that on specific weekend dates, there was insufficient RN coverage. The Administrator confirmed in an interview that the facility did not have 8 hours of RN coverage on these identified days. The Director of Nursing (DON) stated in an interview that while the facility policy requires an RN to be onsite for 8 hours daily, they were not always able to schedule RNs for weekend shifts, despite their efforts. Facility policy review confirmed the requirement for daily RN coverage.
Unqualified Dietary Manager and Insufficient Food Service Staffing
Penalty
Summary
The facility failed to employ a qualified individual to serve as the director of food service in the absence of a full-time dietitian. Record review of the Dietary Manager's (DM) employee file showed no evidence of a Dietary Manager Certificate. The DM confirmed during interview that she did not possess a dietary manager certification, had not registered for any certification classes, and cited financial constraints as the reason for not pursuing certification. The DM had been working in the dietary department for three years and was appointed as Dietary Manager in January 2025 without the required certification. Further interviews revealed that the facility's dietitian was contracted to visit only quarterly, with the last visit occurring in September. The dietitian acknowledged awareness of the DM's lack of certification and had previously provided information on online courses to both the administrator and the DM, but was unaware of any progress. The administrator also confirmed knowledge of the DM's uncertified status and lack of application for certification. The job description for the Dietary Manager required management of dietary operations in accordance with facility policies and regulations, but the DM did not meet the certification requirements.
Failure to Maintain Laundry Hot Water Heater in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the hot water heater for the laundry in safe operating condition, resulting in the absence of hot water for laundry operations for approximately two months. Observations confirmed that the hot water heater was not functioning, with no hot water available at the washing machine or handwash sink, and the heater itself was cold to the touch. Laundry staff reported that the hot water had been out for several months and that both the Maintenance Director and Administrator were aware of the issue and had attempted repairs without success. During this period, laundry staff used bleach for sanitizing laundry in the absence of hot water. The Maintenance Director stated that the hot water heater had been out of service for as long as he had worked at the facility, which was four months, and that an incorrect part had been ordered, delaying repairs. The Administrator also acknowledged the ongoing issue but could not specify the duration. Facility policy requires the Maintenance Department to keep all equipment, including plumbing fixtures, in safe and operable condition at all times, which was not met in this instance.
Failure to Maintain Resident Room Furnishings and Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for two residents, as evidenced by damaged window blinds and missing furniture components in their rooms. Observations revealed that one resident's room had a broken window blind that did not block sunlight and a chest of drawers with a missing bottom drawer. The resident reported that these issues were present upon moving in and made the room appear unkempt, though no formal complaint had been made. The resident's representative confirmed the damage was present at admission and had mentioned it to staff, but could not recall specifics. Another resident's room was observed to have a window blind with missing and broken blades, allowing constant sunlight into the room. This resident stated the blind had been broken for a long time and had not reported it to staff, expressing dissatisfaction with the room's appearance. The facility's administrator was unaware of the damaged items in both rooms until the time of the survey. Facility policy assigns responsibility for maintaining the building and equipment in a safe and operable manner to the Maintenance Department.
Failure to Maintain Effective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of a live lizard in the kitchen area above the dishwashing machine and 3-compartment sink. Staff interviews confirmed that lizards had been seen in the kitchen before, although no other pests such as roaches or bugs were reported. The Dietary Manager (DM) acknowledged seeing lizards but was unsure of their origin and could not recall to whom she reported the sightings. The Maintenance Director revealed that the facility did not have a current pest control contract and had not seen any pest control services performed during his four-month tenure. The last documented pest control service was several months prior, with services discontinued due to non-payment. The Administrator was aware that the pest control vendor had stopped services for non-payment but was not aware of any lizard issues in the dietary area. Facility policy required maintaining an insect and vermin-free food service department, including structural measures to prevent pest entry, but these measures were not effectively implemented.
Failure to Provide Accessible and Functional Call Light System
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, a history of repeated falls, and total dependence on staff for activities of daily living was found without access to a working call light system in her room. Observation revealed that the call light on the wall did not have any means to activate the call system, and the resident confirmed she had no way to call for help except by yelling. The resident's care plan specifically included an intervention for the call light to be within reach due to her fall history. Interviews with the resident and the facility administrator confirmed the lack of an operational call system in the resident's room. The administrator was unaware of the issue and could not provide a reason for the failure. Facility policy required that call lights be accessible and within reach of residents, but this was not followed in this instance.
Failure to Timely Pay Utility Bills Resulting in Risk to Essential Services
Penalty
Summary
The facility failed to manage its financial resources effectively, resulting in multiple unpaid utility bills for essential services such as water, gas, and electricity. Invoices and disconnect notices from vendors revealed that the facility had accumulated significant past due balances, with some disconnection dates already passed. The Administrator (ADM) reported that her role was limited to forwarding bills to Accounts Payable and the CEO, and she was not involved in payment decisions or aware of which bills were ultimately paid. The CEO confirmed that payments were only made when he instructed the accounts management company, and he was unable to provide payment receipts at the time of the survey. Interviews with utility vendors confirmed repeated attempts to collect payment, including calls and emails to the CEO, with some vendors delaying disconnection out of consideration for the residents. Observations during the survey confirmed that the facility continued to have water, electricity, and gas services at the time. Review of the facility's governing board policy indicated that the board is responsible for ensuring the provision of a safe physical environment and oversight of facility care and services. However, the failure to pay utility bills in a timely manner, as evidenced by the documentation and interviews, demonstrated a lack of effective administration and resource management, which could impact the facility's ability to maintain essential services for residents.
Failure to Timely Pay Essential Service Vendors Resulting in Past Due Balances
Penalty
Summary
The facility failed to administer its operations in a manner that ensured timely payment of essential service vendors, resulting in significant past due balances. Specifically, the facility accumulated a four-month overdue balance with the water vendor, leading to a disconnection notice, and a three-month overdue balance with the fire vendor for services provided in previous months. Invoices and disconnection notices were received and forwarded to Accounts Payable, but payments were not made in a timely manner. The Administrator was aware of the outstanding balances and had forwarded the bills and notices to Accounts Payable, but did not have authority to make payments directly. The COO confirmed that bill payments were determined in weekly meetings between Accounts Payable and the CEO, with emergency payments made only in urgent situations. The CEO stated that bills were sent to an independent company for review and payment, and was unaware of the extent of the past due balances until after the disconnection notices were issued. The water vendor had issued a disconnect notice for non-payment, and the fire vendor considered disconnecting the facility's fire alarm and placing it on fire watch due to the overdue balance. Despite these overdue accounts, water services remained active at the time of the survey. The facility was unable to provide a policy regarding vendor payment prior to the survey exit.
Failure to Provide Required RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, as evidenced by a review of RN timesheets and staff interviews. Specifically, there was no RN coverage for 17 days, including multiple Saturdays and Sundays, as confirmed by the Director of Nursing (DON) and the Administrator. The DON acknowledged that the facility did not have RN coverage on weekends and that management was aware of this issue. The Administrator also confirmed that the facility's policy requires daily RN coverage, but admitted that this standard was not consistently met. The medical director was aware of the lack of RN coverage, particularly on weekends, and noted that management had decided to accept the consequences of this deficiency. There was an instance where a physician had to pronounce a death on a weekend due to the absence of an RN. The facility's staffing policy requires an RN to be onsite for 8 consecutive hours each day, but this requirement was not fulfilled on the identified dates.
Failure to Provide Ordered X-ray Services
Penalty
Summary
The facility failed to provide or obtain necessary radiology services for a resident who had a fall and was ordered an x-ray by the physician. The resident, an elderly male with a history of atherosclerotic heart disease, dementia, and osteoarthritis, fell and complained of shoulder and collarbone pain. Despite the physician's order for an x-ray, the facility was unable to schedule the service with the mobile x-ray company. There was no documentation of further attempts to secure the x-ray or communication with the physician regarding the inability to obtain the service. The Director of Nursing (DON) and the nurse involved were aware of the physician's order but failed to ensure the x-ray was conducted. The nurse attempted to contact the mobile x-ray company multiple times without success and texted the physician but did not receive a response. The nurse did not follow up with the physician or inform the DON or the next shift about the issue. Consequently, the x-ray was never performed, and the resident did not receive the ordered diagnostic service, potentially impacting the resident's care.
Deficiency in RN and DON Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for 8 consecutive hours a day, 7 days a week, for 22 days out of a 79-day period from September 1, 2024, to November 18, 2024. Additionally, the facility did not employ a full-time Director of Nursing (DON) for 19 of those 79 days. This deficiency was identified through interviews and record reviews, which revealed that the absence of an RN and a full-time DON placed residents at risk for altered physical, mental, and psychological well-being. The facility's staffing data confirmed the lack of RN coverage on specific dates, and interviews with the Chief Nursing Officer (CNO) and the Administrator highlighted challenges in maintaining consistent RN coverage, particularly on weekends. The CNO and Administrator acknowledged the staffing issues, citing difficulties in recruiting staff in a rural area and the transition between DONs as contributing factors. The facility relied on telehealth services and access to a corporate RN to mitigate the impact of the RN absence. However, the CNO and other staff members admitted that residents requiring RN-level care were transferred to the hospital when necessary. The facility's policy required an RN to be onsite for 8 consecutive hours daily, but this standard was not met consistently, leading to the identified deficiency.
Deficiencies in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 38 out of 40 residents. The low-temperature dishwashing machine lacked a chemical sanitizer, and dietary staff were not trained to check the chlorine sanitizer content, resulting in the machine operating without proper sanitization. Additionally, the facility's kitchen and storage areas were found to be in unsanitary conditions, with soiled food carts, open and undated food items, mold in the ice machine, and dirty appliances and floors. Interviews with dietary staff revealed a lack of training and awareness regarding the dishwashing machine's operation and the absence of a chemical sanitizer. Dietary staff were unaware of how to test the machine, and the chemical sanitizer had been out for less than a week. The facility had not had a dietary manager since the beginning of October, and the administrator was unaware of the sanitizer issue due to a delay in vendor payment. The maintenance director had informed corporate about the low sanitizer levels but was unsure of how long it had been out. The facility's policies on dishwashing machine use and sanitization were not followed, as evidenced by the lack of training for food service staff and the failure to maintain cleanliness in the kitchen and dining areas. The dishwashing machine's sanitizer concentration was below the required levels, and the facility's failure to maintain sanitary conditions could place residents at risk for foodborne illnesses.
Failure to Refer Resident for PASRR Re-evaluation
Penalty
Summary
The facility failed to refer a resident for a PASRR screening and evaluation after the resident developed a newly evident mental disorder. The resident, a female with a diagnosis of unspecified dementia, was admitted to the facility without a diagnosis of mental illness. However, she was later diagnosed with major depressive disorder and exhibited potential indicators of psychosis, such as hallucinations and delusions, as noted in her MDS assessment. Despite these changes, the facility did not refer her for a PASRR re-evaluation, which is necessary to ensure that residents with mental illnesses receive appropriate services and care. The MDS coordinator acknowledged the absence of a 1012 form, which is used to determine if a resident has a mental illness diagnosis, and admitted that the resident had not received PASRR services. The facility's policy requires a PASRR Level 1 screening to identify individuals suspected of having mental illness, intellectual disability, or developmental disability. The failure to conduct a PASRR re-evaluation placed the resident at risk of not receiving adequate services related to her mental health needs.
Failure to Complete PASARR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness received the necessary Preadmission Screening and Resident Review (PASARR) Level II evaluation. The resident, who was admitted with a primary diagnosis of Atherosclerotic Heart Disease and secondary diagnoses including Unspecified Dementia, Bipolar Disorder, Schizophrenia, and Schizoaffective Disorder, did not have a PASARR Level II screening completed. Despite having active diagnoses of mental health conditions, the resident's PASARR Level I screening indicated no evidence of mental illness, and no PASARR Level II screening or form 1012 was found in the clinical record. Interviews with the MDS Coordinator and the Chief Nursing Officer revealed that the facility was aware of the oversight. The MDS Coordinator acknowledged that the resident should have had a PASARR Level II evaluation or a 1012 form completed due to the qualifying diagnosis. The Chief Nursing Officer confirmed the lack of a PASARR Level II evaluation and recognized the potential negative outcome of the resident not receiving specialized services. The facility's policy indicated that if documentation on the PL1 shows mental illness, intellectual disability, or developmental disability, a PASARR Level II evaluation must be completed, which was not adhered to in this case.
Failure to Timely Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans within the required timeframe for two residents, leading to a deficiency. Resident #36, a male with multiple diagnoses including chronic pancreatitis, hypertension, and schizophrenia, was admitted on a specified date, but his comprehensive care plan was not completed until nearly two months later. Despite having a baseline care plan, the comprehensive care plan was delayed, which was confirmed during an interview with the Chief Nursing Officer (CNO). Observations revealed that Resident #36 had concerns about his mood, choices, dental, nutrition, pain management, and genitourinary needs, which were noted in the care plan completed on 10/6/24. Similarly, Resident #38, a female with conditions such as chronic pain, glaucoma, and osteoarthritis, was admitted on a specified date, but her comprehensive care plan was not completed until the CNO was notified. The CNO acknowledged the absence of a comprehensive care plan and emphasized the expectation for timely completion. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the comprehensive assessment, which was not adhered to in these cases.
Inappropriate Prescription of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these medications without a proper diagnosis. Specifically, Resident #13 was administered Depakote and Ativan without an appropriate diagnosis documented in the clinical record. The resident, a female with unspecified dementia and other conditions such as repeated falls and muscle weakness, was diagnosed with major depressive disorder and anxiety disorder. However, the medications prescribed did not align with these diagnoses, as dementia and agitation/aggression are not considered appropriate diagnoses for the administration of Depakote and Ativan, respectively. Interviews with the Regional Nurse Consultant and the Chief Nursing Officer (CNO) confirmed that the diagnoses used for prescribing these medications were inappropriate. The facility's policy on antipsychotic medication use requires that such medications be prescribed only for specific conditions identified through a comprehensive assessment. The policy also mandates that antipsychotic medications be used at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. The failure to adhere to these guidelines could potentially affect other residents receiving medications in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions (EBP) for three residents with specific medical conditions that required such measures. Resident #9, who had a gastrostomy tube, did not have any physician orders for EBP, nor was there any focus, goal, or intervention for EBP in his care plan. Observations revealed no EBP signage or personal protective equipment (PPE) available in his room. Similarly, Resident #28, who had a stage 4 pressure ulcer, also lacked physician orders for EBP and had no related focus, goal, or intervention in her care plan. Observations of her room showed the absence of EBP signage and PPE. Resident #91, with a PICC line for antibiotic infusion, was also not placed on EBP, with no signage or PPE available in her room. Interviews with staff, including an LVN, MA, CNA, and the CNO, revealed a lack of consistent implementation and understanding of EBP. The CNO admitted that EBP signage was only posted after realizing it was missing, indicating an oversight and lack of consistent leadership. The facility's policy on EBP was not effectively followed, as evidenced by the absence of necessary precautions for residents with wounds or indwelling medical devices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Nocona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Rehabilitation And Healthcare Of Bowie | 17.2 mi | ★★★★★ | 2 | 0 |
| Grace Care Center Of Henrietta | 27.1 mi | ★★★★★ | 2 | 0 |
| Wilson Nursing Center | 31.9 mi | — | 0 | 0 |
| Avir At River Valley | 34.6 mi | ★★★★★ | 17 | 0 |
| Lake Country Nursing Center | 36.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.