Concho Health & Rehabilitation Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
#1 on 10/17/2025 at 1:46PM revealed she was in bed with eyes closed lying on her back. An interview with
the Administrator on 10/17/25 at 1:45 P.M. revealed she did not report the allegation from Resident #1, as
the allegation occurred outside the facility. She stated RNC reported Resident #1's allegation to her. She stated she did call the ADO but did not follow up because the allegation occurred outside the facility.
However, upon reviewing the abuse guidelines from HHSC, she stated she should have reported the incident.An interview with the ADO on 10/17/25 at 9:20 AM revealed they did not report this allegation to
the State office when it was first reported to the Administrator on 10/12/2025. It was not reported to the State office until 10/16/2025 after ADO and Regional Compliance nurse read the progress notes. They were performing an audit of Resident #1's chart prior to readmission and read the residents allegations in
the progress note. ADO stated they did not have a DON at the facility at this time and the DON reviewed all progress notes. She stated the Administrator attempted to call her on 10/12/2025 but they did not speak, and no messages were left. The ADO stated she was traveling at that time and unable to answer. She stated her expectations are for the Administrator to leave a message or continue to call. The ADO stated
she did not follow up because she was traveling and forgot to return the phone call. On 10/17/2025 at 10:30AM the surveyor attempted to reach the RN C with no success. The surveyor left a message but did not receive a return call. An interview with DON on 10/17/2025 at 2:30PM revealed she was not employed
on the date this allegation occurred. She was the current Interim DON and started on 10/15/2025 and does not have access to electronic health records as of this time. She stated her expectation is for and abuse, neglect, or misappropriation to be reported to her or the Administrator immediately. Record review of facilities in-service records revealed a one-on-one written in-service dated 10/17/2025 with the administrator, DON, ADON, and MDS coordinator regarding reporting every allegation of abuse or neglect to HHSC per guidelines. Abuse and Neglect in-services were started on 10/16/2025 with facility policy labeled Abuse and Neglect attached. Record review of Texas Unified Licensure Information Portal (TULIP)
on 10/16/25 at 4:30 P.M. revealed no self-reported incidents regarding allegations of abuse were reported for Resident # 1 . Record review of undated facility policy on 10/17/2024 titled, Abuse, Neglect revealed: 1.
Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants and volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 2. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to
the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet
the criteria of Provider Letter 2024-14 dated 8/29/2024.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record Review of Provider Letter 2024-14 dated 8/29/2024 revealed a nursing facility must report the following types of incidents, in accordance with applicable state and federal requirements: abuse, neglect, exploitation, death due to unusual circumstances, a missing resident, misappropriation, drug theft, suspicious injuries of unknown source, fire, emergency situations that pose a threat to resident health and safety, communicable disease situations that are an unusual or abnormal event that poses a threat to resident health and safety.
Do report abuse or an incident that results in serious bodily injury immediately but not later than two hours
after the incident occurs or is suspected. Do report an incident that does not result in serious bodily injury immediately but no later that 24 hours after the incident occurs or is suspected.
Event ID:
Facility ID:
If continuation sheet
CONCHO HEALTH & REHABILITATION CENTER in EDEN, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EDEN, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CONCHO HEALTH & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.