Concho Health & Rehabilitation Center
Inspection Findings
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for accuracy and completeness.Facility failed to document that Resident #1 wound care was completed on 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. This deficient practice could put residents at risk of not receiving needed services although services are documented as having been provided. Record review of Resident #1's detailed summary report/face sheet dated 12.18.25 indicated he was admitted to facility on 11.17.25 with diagnoses of heart failure, anemia, and type 2 diabetes. Record review of Resident #1's Minimum Data Set (MDS) dated 11.25.25 indicated the Brief Interview Mental Status (BIMS) score = 14 indicating resident had no impairment. Record review of Resident #1's care plan dated 12.18.25 indicated the resident has a pressure ulcer or potential for pressure ulcer development. The resident's pressure ulcer will show signs of healing and remain free from infection. Avoid positioning the resident on the location of the pressure ulcer. During
an interview on 12.18.25 at 9:25 a.m., Resident #1 stated he does get his wound care as ordered by his physician. He stated he has never had an issue with his wound care and all of his wounds were healing. He stated he has never missed wound care. Record review of Resident #1's TAR indicated missed wound care for dates of 12.9.25, 12.13.25, 12.17.25, 12.19.25 and 12.22.25. During an interview on 12.18.25 at 2:15 p.m., the DON stated that she knows all residents get their wound care. She stated that if there was a blank
in the TAR, this indicated an employee did not click that the care was completed. She stated but none of the residents in the facility have ever missed their wound care. During an interview on 12.18.25 at 2:35 p.m., LVN A stated that the gap in a TAR indicated that the wound care was either not done or the employee did not click complete in the electronic tracking system indicating the task was completed. She stated the miss
on 12.19.25 for Resident #1 was on her shift but she remembers directly that she did do the residents wound care. She stated she must have gotten super busy and just forgot to click that the treatment was completed. She stated overall this can happen sometimes because it gets so busy in the facility. During an
interview on 12.18.25 at 2:45 p.m., RN B stated she made sure to do everyone's wound care. She stated when looking at Resident #1's TAR she does see the gaps and stated that does not mean the residents missed their care it means whoever provided the care did not click out of the system notifying that the task was completed. She stated for example Resident #1's treatment on the 22nd she knows she did it but might have gotten distracted to help another resident or by other staff and just didn't click completed. Record
review of facility policy titled documentation, not dated indicated: Goal-1. the facility will maintain complete and accurate documentation for each resident on all appropriate clinical records sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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.