Mexia Ltc Nursing And Rehab
MEXIA LTC NURSING AND REHAB in MEXIA, TX — inspection on November 15, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to revise Resident #1's care plan to reflect interventions for falls related to unsteadiness during transfers and only able to stabilize with staff assist initiated on 10/28/20 and revised on 07/26/22.
This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.
Findings Included:
Record review of Resident #1's admission record dated 11/14/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: type 2 diabetes (pancreas doesn't make enough insulin, essential hypertension (high blood pressure), muscle weakness (loss of muscle strength), and lack of coordination (damage or brain coordination system).
Record review of Resident #1's Quarterly MDS assessment, dated 09/22/25, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact.
Record review of Resident #1's care plan, dated 10/27/25, revealed Resident #1 was care planned on 10/28/20 and revised on 07/26/22 for falls related to unsteadiness during transfers and only able to stabilize with staff assist.
During an interview on 11/15/25 at 1:28 p.m., the DON stated it was expected for the care plans to be accurate and updated.
The DON stated that the MDS Coordinator was responsible for updating the care plans.
The DON stated that care plans were detailed communication of the residents so staff would know how to assist a resident.
The DON stated when the interventions were not in place staff would know how to care for the residents .
During an interview on 11/15/25 at 1:30 p.m., the MDS Coordinator stated he was responsible for updating the care plans.
The MDS Coordinator stated he was expected for him to update the care plan with the interventions so staff would know how to assist the residents.
The MDS Coordinator did not have a reason why Resident #1 fall intervention was not updated in the care plan and he could not recall.
Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 revised December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mexia Ltc Nursing and Rehab
601 Terrace LN Mexia, TX 76667
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities, for 4 of the facility's 4 halls (Halls 100, 200, 300, 400) reviewed for resident call system, The facility failed to have a functioning call light system for residents who resided in the facility on Halls 100, 200, 300, and 400 when the call system failed on 11/11/25 and was still down 11/15/25.
This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.
Findings included: During an observation on 11/14/25 at 1:10 p.m. through 1:40 p.m., the call lights on Halls 100, 200, 300, and 400 were not working and the residents were using cow bells and staff were making rounds to check if a resident needed assistanceDuring an observation on 11/15/25 at 10:30 a.m. through 10:50 a.m., the call bells was heard ringing, and staff were able to assist the residents also with making rounds.
During an interview on 11/14/25 at 1:30 p.m., the DON stated the call light system stopped working on 11/11/25 around 10:30 a.m.
The DON stated the facility went out and purchased call bells and were given to all residents that could physically use a call bell and staff made rounds every 30 minutes on all the residents and more frequently, every 15 minutes on the residents that were not able to use a call bell.
The DON stated that there have not been any injuries or illnesses since the call light system has been down and the call bells have been working until the call system is fixed.
The DON stated the maintenance director came out 11/11/25 and could not figure out the malfunction and a technician was called out.
The DON did not have any information on when the call system would be up and running.
The DON stated the expectations were to provide calls bells to residents that were cognitive of ringing the bell and staff were in-serviced to ensure rounds will be made every 15 - 30 minutes to ensure residents' needs were being met.
During an interview on 11/14/25 at 2:05 p.m., the Maintence Director stated he had checked the call system weekly.
The Maintence Director stated with his weekly checks the call system had been functioning.
The Maintence Director stated the entire call system went out on 11/11/25.
The Maintence Director stated a technician was sent out and he did not know the estimated time frame of when the call system would be up and running.
The Maintence Director stated when the call system went out on 11/11/25 the facility went and purchased call bells for the residents.
The Maintence Director stated he never had an issue with the call system going completely out and the call bells would be used until the call system is fixed.
The Maintence Director stated it was expected for the call system to be working at all times so residents can communicate to staff their needs.
During an interview on 11/14/25 at 4:00 p.m., the RN stated it was expected for staff to answer the call bells immediately once the call bell system went down.
The RN stated that there had not been any illnesses or accidents with any residents since the system went down on 11/11/25.
The RN stated a technician stated that a chip will need to be replaced and it will be repaired in less than two weeks.
The RN stated that staff make rounds every 15 to 30 minutes.
Record review of the facility's policy titled, Call System, Resident, dated September 2022, indicated, Residents are provided with a means to call staff for assistance through communications system that directly calls a staff member of a centralized workstation.
The resident call system remains functional at all times. If audible communication is used, the volume is maintained an audible level that can be easily heard. If visual communication is used, the lights remain functional.
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