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 Reagan County Care Center during CMS and state inspections, most recent first.
The facility failed to conduct and document an annual facility assessment to determine the resources needed to care for residents competently during routine operations and emergencies. Record review showed the prior assessment was completed years earlier, and the Administrator stated he had never completed a facility assessment and did not remember the requirement to update it annually, despite believing he had been trained on it.
An opened Aplisol Tuberculin solution in a medication room refrigerator was found without an open date label. The ADON stated TB solution must be dated when opened and is good for 28 days, and the DON confirmed nurses were responsible for dating opened medication and that the vial should have been dated when opened.
Failure to post daily nurse staffing information in a prominent, accessible location. Surveyors observed the staffing sheet behind the nurses' station on multiple occasions, making it inaccessible to residents and visitors. The ADON said the sheet was updated each morning by her or the night nurse, and the DON and Administrator acknowledged the expectation that it be visible in the hallway for residents and visitors to see how many staff were available each shift.
A resident with cerebral palsy, depression, and CKD, who used a wheelchair and had moderate cognitive impairment, was identified in an IDT meeting with a PASRR Habilitation Coordinator and MDS Coordinator as needing NFSS items including a customized manual wheelchair, gait trainer, and orthotics, which remained pending for about a year. The resident reported that measurements had been taken and equipment demonstrated but believed facility paperwork had not been approved, while observation showed the resident propelling the oversized wheelchair by pulling on hallway handrails. The MDS Coordinator, responsible for entering NFSS data into the LTC online portal, reported repeated submission errors, lack of effective assistance from external contacts, and no PASRR training despite years at the facility. The Administrator and DON were unaware of the incomplete PASRR process and the MDS Coordinator’s lack of training, and the facility could not provide a PASRR policy when requested by surveyors.
The facility did not submit required Payroll Based Journal (PBJ) staffing data to CMS for a full quarter, as confirmed by review of staffing reports and staff interviews. The CFO, responsible for the submission, was unaware of the confirmation process and did not follow up, resulting in no data being submitted for the period despite having the necessary information.
A CNA failed to change contaminated gloves and did not clean a resident’s penis area during incontinent care, instead continuing care and handling equipment with the same gloves. This was not in accordance with the resident’s care plan and facility infection control policies, as confirmed by interviews with the DON and Administrator.
A resident's care plan was not updated to reflect the removal of an indwelling urinary Foley catheter, despite documentation and staff confirmation that the catheter had been discontinued. The care plan continued to include interventions for catheter care, contrary to the resident's current status. This lapse was identified through record review, staff interviews, and observation.
A maintenance staff member with a moustache and beard entered the kitchen to repair equipment while food was being prepared, but did not wear a required beard restraint. Facility policy and posted signage required all staff to use hair and beard coverings in the kitchen to prevent contamination, and interviews confirmed this expectation.
The facility failed to maintain a landscaped area on the back patio free of cat feces, leading to unsanitary conditions. Observations revealed visible cat feces and dug-out dirt, with a slight fecal odor. The Maintenance Director and Administrator acknowledged the issue, and there was no formal policy regarding the care of the cats.
The facility failed to complete a Significant Change MDS assessment within 14 days after a resident was admitted to hospice services. Despite the resident's significant change in condition, the care plan was not updated, and the required MDS assessment was not completed. The MDS consultant was not informed of the resident's hospice admission, and the facility's administrator acknowledged the oversight.
The facility failed to maintain an infection prevention and control program, as staff did not properly store SVN masks for two residents and did not follow proper hand hygiene protocols during incontinent care for another resident. These failures were observed during a survey and confirmed through interviews and record reviews.
The facility failed to update a resident's care plan to reflect her hospice status, despite a physician's order and multiple diagnoses. Miscommunication and lack of oversight among staff and the contracted MDS consultant contributed to this deficiency.
The facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments. The discontinued controlled medication cabinet in the DON's office had only one functioning lock, and several staff members had access to the office, increasing the risk of unauthorized access to medications.
Failure to Complete Annual Facility Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Record review showed the most recent Facility Assessment was completed on 7/1/26, while the prior assessment had been completed on 10/18/21, indicating the facility had not completed an annual update for 2021, 2022, 2023, 2024, and 2025. In interview, the Administrator stated he had never completed a facility assessment and did not remember the requirement to complete and update it annually, although he believed he had been trained previously. He acknowledged this was a failure on his part and stated he did not think it would result in negative consequences because the facility scheduled more than enough staff and had plans to move staff around during each shift if staff were absent.
Opened Tuberculin Solution Lacked Required Open Date
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. During observation on 6/30/2026 at 10:30 AM, the refrigerator in Medication room [ROOM NUMBER] contained an opened Aplisol Tuberculin solution that did not have an open date labeled. The report identified this as 1 of 1 medication rooms with Tuberculosis solution that was not labeled with an open date. During interview on 6/30/2026 at 10:41 AM, the ADON stated that once Tuberculosis solution is opened, it must be labeled with the open date and is good for 28 days after opening. She said the vial had been opened on Saturday 6/27/2026 when a new admit arrived and only one dose was used. During interview on 6/30/26 at 12:36 PM, the DON stated the Tuberculosis solution should be dated when opened, that nursing management was responsible for checking and auditing carts and medication rooms after the nurses, and that nurses were responsible for dating the medication when opened. Record review of the Recommended Medication Storage policy stated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a different date.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information in a prominent location readily accessible to residents, visitors, and staff. During observations on 06/30/2026 at 9:50 a.m., 07/01/2026 at 11:30 a.m., and 07/02/2026 at 10:15 a.m., the staffing posting was observed behind the nurses' station and not accessible to residents and visitors. The report states the posting was not in a readily accessible place for visitors and residents. During interviews, the ADON stated the staffing sheet was updated every morning by her or the night nurse and that the purpose of the daily staffing sheets was so family and residents were aware of how many staff were available. The DON stated it had been the night nurse's responsibility to update the staff posting and that he would move the clipboard to where it was visible on the hallway. The Administrator stated the expectation was that daily staffing was posted where it was accessible by residents and visitors, and that the Daily Staffing Sheet should show everyone how many staff were available each shift. The facility policy titled, Posting Direct Care Daily Staffing Numbers, August 2022, stated the facility would post daily nurse staffing data within two hours of the beginning of each shift in a prominent location accessible to residents and visitors.
Failure to Implement PASRR Recommendations and Complete NFSS Submission
Penalty
Summary
The deficiency involves the facility’s failure to incorporate PASRR evaluation recommendations into a resident’s assessment, care planning, and transition of care, and to submit a complete and accurate NFSS request in the LTC online portal within the required timeframe. The resident was an adult male with cerebral palsy, depression, and chronic kidney disease, with a BIMS score indicating moderate cognitive impairment, who used a wheelchair for mobility and was able to understand and be understood by others. His care plan documented that he was PASRR positive related to a developmental disability and that he would participate in quarterly care plan meetings with a PASRR representative, with coordination of PASRR services and development of an Individual Service Plan by the PASRR representative. At a quarterly IDT meeting, attended by the PASRR Habilitation Coordinator, the MDS Coordinator, and the resident, several NFSS items were identified and confirmed as pending, including a customized manual wheelchair, a gait trainer, and orthotic devices. The PASRR Habilitation Coordinator reported that these items had been requested for almost a year without completion. Observation showed the resident propelling himself in his wheelchair down the hall by pulling on the handrails rather than pushing the wheels, although he was able to reach his destination independently. The resident stated he had been waiting approximately a year for the customized wheelchair, gait trainer, and orthotics, that a representative had measured him and shown him a chair, and that he understood the paperwork from the facility had not been approved. He also reported being told by the Physical Therapist that his current chair was too big, though he denied experiencing negative outcomes. The MDS Coordinator stated it was her responsibility to enter the NFSS form into the LTC online portal and that she had repeatedly attempted to submit the information but received error messages, which she reported to the PASRR Habilitation Coordinator. She indicated she had sought assistance from the DME company’s Lead PASRR specialist and from the Simple LTC portal but did not receive effective help, and she reported having worked at the facility for seven years without receiving PASRR training. The Administrator acknowledged that the process had been problematic on multiple levels, was unaware of the MDS Coordinator’s lack of PASRR training, and had assumed the paperwork issues were resolved. The DON stated he was unaware that the PASRR process for this resident had not been completed, was not aware of complications, and reported that neither he nor the MDS Coordinator had PASRR training. The physician stated the resident had not had a decline and that any mobility decline would be expected from cerebral palsy rather than from lack of the recommended equipment. When the surveyor requested a PASRR policy, the facility did not provide one prior to exit.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to comply with federal requirements for electronically submitting complete and accurate direct care staffing information to CMS using Payroll Based Journal (PBJ) data. Specifically, the facility did not submit the required PBJ staffing information for Fiscal Year Quarter 1 2025 (October 1 - December 31). Review of the CASPER Report 1705D for this period showed no data was submitted for the quarter, triggering a deficiency. The facility's employee list indicated the presence of various staff, including RNs, LVNs, CNAs, and other personnel, and the census showed a total of 27 residents at the time of the deficiency. During an interview, the Chief Financial Officer (CFO) stated that this was her first time submitting the PBJ data independently and believed she had completed the process, but later realized the submission did not go through. The CFO was unaware that an email confirmation was required and did not follow up, resulting in the missed deadline and inability to submit the data retroactively. The deficiency was identified through record review and staff interview, with no PBJ data available for the specified quarter.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during incontinent care for a resident with Alzheimer’s disease and aphasia, who was at risk for skin breakdown and infection due to frequent bladder and bowel incontinence. During an observed episode of incontinent care, a CNA did not change her gloves after they became contaminated and did not clean the resident’s penis area as required by the care plan and facility policy. The CNA continued to use the same gloves while performing multiple tasks, including cleaning the resident’s buttocks, applying barrier cream, fastening a new brief, adjusting the resident’s clothing, and handling equipment for a transfer. Interviews with the DON and Administrator confirmed that the expected practice was for CNAs to change gloves once contaminated and to perform complete peri-care, including cleaning the penis area. Facility policies reviewed indicated the need for thorough perineal care and proper hand hygiene, including glove changes and hand sanitization after contact with potentially contaminated surfaces. The observed failure to follow these procedures was not in accordance with the facility’s infection control protocols.
Failure to Update Care Plan After Foley Catheter Removal
Penalty
Summary
The facility failed to update and revise the care plan for a resident after the removal of an indwelling urinary Foley catheter. The resident, who had diagnoses of overactive bladder and Parkinson's disease, was admitted with a Foley catheter in place due to benign prostatic hyperplasia with urinary retention. Although the catheter was discontinued per physician order and documented in the nursing notes, the care plan continued to list interventions and goals related to catheter care. Multiple staff interviews confirmed that the resident no longer had a catheter, and the resident himself reported using a urinal instead. However, the care plan was not updated to reflect this change in the resident's status. The MDS coordinator acknowledged that the care plan should have been revised to remove references to the indwelling catheter after its discontinuation, but this update was missed. The facility's policy requires care plans to be revised as resident conditions change, and the Director of Nursing confirmed that the MDS coordinator is responsible for these updates. The failure to revise the care plan was identified through record review, staff interviews, and direct observation, demonstrating a lapse in ensuring that care plans accurately reflect current resident needs.
Failure to Enforce Beard Restraint Policy During Kitchen Maintenance
Penalty
Summary
Ground Maintenance Man D was observed in the facility's kitchen during food preparation without wearing a moustache or beard guard, despite having visible facial hair. A sign posted at the kitchen entrance clearly indicated that hairnets and beard restraints were required beyond that point. The maintenance staff member entered the kitchen to repair the food disposal while food was uncovered and being prepared by kitchen staff. Interviews with the maintenance staff, the Dietary Supervisor, and the Administrator confirmed that the expectation was for all staff, including maintenance personnel, to wear appropriate hair and beard restraints when entering the kitchen to prevent hair from contaminating food. The maintenance staff member acknowledged forgetting to wear his mask during the incident. Review of the facility's policy also confirmed the requirement for hair and beard restraints to be worn to prevent contact with exposed food and clean equipment.
Unsanitary Conditions Due to Cat Feces on Back Patio
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not maintaining a landscaped area on the back patio free of cat feces. Observations revealed visible cat feces and multiple areas of dirt dug out by animals, with a slight fecal odor noted. The Maintenance Director confirmed that his team cleaned the area 2-3 times a week but acknowledged that the smell became an issue during hot weather. The Administrator admitted that the area under the tree was used by cats as a makeshift litterbox and agreed that it was a problem. There was no facility policy regarding the care of the cats, but the Administrator mentioned working on creating one. The report also referenced information from the CDC about the risks of toxoplasmosis, a parasitic infection that can be spread through cat feces. This highlights the potential health risks associated with the unsanitary conditions observed. The lack of a formal policy and the current cleaning efforts were insufficient to address the issue, leading to the deficiency noted in the report.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after a resident was admitted to hospice services. Resident #11, a female with a history of atherosclerotic heart disease, dementia, anxiety disorder, and major depressive disorder, was admitted to hospice care with a diagnosis of hypertensive heart disease with heart failure. Despite this significant change in condition, the facility did not update the resident's care plan or complete the required MDS assessment within the mandated timeframe. The resident's Quarterly MDS assessment indicated moderately impaired cognition, but no Significant Change MDS was found in the records. Interviews revealed that the MDS consultant, who took over on March 1, 2024, was not informed of the resident's hospice admission and mistakenly believed the resident was already an ongoing hospice patient. The Assistant Director of Nursing (ADON) stated that the MDS consultant was responsible for completing the MDS assessments and was made aware of the resident's status. The facility's administrator acknowledged that the ultimate responsibility for ensuring the completion of the MDS assessment lies with the facility, despite the consultant being contracted to perform these tasks. The facility's policy on changes in a resident's condition requires a comprehensive assessment and care plan revision, which was not adhered to in this case.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not properly store SVN masks for two residents and did not follow proper hand hygiene protocols during incontinent care for another resident. These failures were observed during a survey and confirmed through interviews and record reviews. Resident #5, who has dementia and chronic obstructive pulmonary disease (COPD), was observed with her SVN mask laying on top of her couch instead of being stored in a bag. Resident #5 confirmed that staff usually stored the mask in a bag but did not have one available at the time. Similarly, Resident #26, who also has COPD, was observed with her SVN mask on her bedside dresser and not stored in a bag. Resident #26 was unaware of the need to store the mask in a bag. RN B confirmed that the masks should be stored in a bag to prevent infections. Additionally, CNA A failed to wash or sanitize her hands after removing gloves and before putting on a new pair while assisting Resident #6 with incontinent care. Resident #6 has mild intellectual disabilities and generalized anxiety disorder and is frequently incontinent. CNA A admitted that she should have washed or sanitized her hands between glove changes to prevent cross-contamination. The facility's policies on respiratory therapy and standard precautions were not followed, leading to potential risks of cross-contamination and infection among residents.
Failure to Update Care Plan for Hospice Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically not updating the care plan to reflect the resident's hospice status. The resident, an elderly female with multiple diagnoses including atherosclerotic heart disease, dementia, anxiety disorder, and major depressive disorder, was admitted to hospice care as per a physician's order. However, the care plan dated after the hospice admission did not include this critical update. Interviews with facility staff revealed a lack of communication and responsibility regarding the creation and updating of care plans. The MDS consultant, who was contracted to complete all care plans, was not kept informed about the resident's hospice status and was under the impression that the resident was already an ongoing hospice patient. The Assistant Director of Nursing (ADON) and the Administrator both indicated that the MDS consultant was responsible for care plans, but the consultant was rarely present in the facility. This miscommunication and lack of oversight led to the failure in updating the resident's care plan to reflect her hospice status.
Failure to Properly Secure Controlled Medications
Penalty
Summary
The facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments. During an observation and interview, it was noted that the discontinued controlled medication cabinet in the DON's office only had one functioning lock. The medications were stored in the bottom drawer of a two-drawer filing cabinet that was bolted to the wall. The bottom drawer had an external padlock on the left side, but the built-in lock on the top right side was non-functional due to a lost key. The ADON confirmed that the cabinet was not being used to store the discontinued medications properly and that initially, there was a second padlock on the right side of the bottom drawer, but it had to be removed because the drawer was getting stuck when opened. The ADON also mentioned that several staff members, including the DON, herself, the Administrator, and possibly the housekeeping staff, had keys to the DON's office, which increased the risk of unauthorized access to the medications. Further interviews revealed that the Housekeeping Supervisor had a master key to the DON's office, but her staff did not have access unless the DON or ADON were present. The Maintenance Director stated that he and his staff also had master keys to all offices in the facility for safety reasons, bringing the total number of people with access to the DON's office to seven. The Administrator acknowledged the issue and agreed that having seven people with access to the office without a double-locked cabinet posed a high risk for drug diversion. At the time of the survey exit, the facility had not provided a policy on medication storage for review.
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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 Big Lake
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crockett County Care Center | 37 mi | ★★★★★ | 0 | 0 |
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