Health inspection·December 11, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #47's Annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #47's admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls, major depressive disorder (persistently depressed mood), alcohol dependence, insomnia (persistent problem falling or staying asleep), mood disorder (different psychiatric conditions that cause changes in a person's emotional state), psychosis (a psychiatric condition that causes a person to lose touch with reality), adjustment disorder with depressed mood (mental health condition when someone has difficulty coping with major stressors or changes in life), quadriplegia (partial or total paralysis in all four limbs and the torso), and alcohol dependence with alcohol induced persisting dementia (a condition that results from chronic alcohol consumption and the resulting brain damage). Record review of Resident #47's Annual MDS with an ARD of 05/20/2024, revealed Section Z of the MDS, Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion revealed sections A, B, C, D, E, F, GG, H, I, J, K, L, M, N, O were signed as completed by MDS Coordinator A on 06/06/2024. Requested a copy of Resident #47's Annual MDS from MDS Coordinator A prior to exit and was provided a copy that only included sections A-I, instead of A-Z. Record review of screen shot of Annual MDS revealed it was signed on 06/06/2024 and highlighted red. Interview on 12/11/24 at 11:14 AM with MDS Coordinator A, who said she was not aware the annual MDS, dated [DATE], for Resident #47 was late and could not account for why it was late. She looked at the EMR and said the date 6/6/24 was highlighted in red because it was late. She said it was possible she was out on leave or PTO or the DON may have signed the MDS late. She said the DON signed all Page 1 of 8 675079 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility MDS' for completion and the MDS should be completed within 14 days of the ARD date so if the ARD was 5/20/24 and the MDS was not completed until 6/6/24 it was actually 17 days and late. MDS Coordinator A said she was responsible for ensuring MDS assessments were submitted on time. She said she used the RAI manual as her policy and procedure for completing the MDS. Interview with the DON on 12/11/24 at 11:29 AM, who said he signed the MDS' for the facility for completion. He said he did not know why or how Resident #47's Annual MDS, dated [DATE], had been completed late. He said in his absence corporate may sign and review or audit MDS'. He said PASRR forms were the sole responsibility of MDS Coordinator A. Record review of CMS's RAI Version 3.0 Manual CH 2: Assessments for the RAI October 2019 Page 2-22 Assessment Management Requirements and Tips for Annual Assessments: than. 675079 Page 2 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessments accurately reflect the resident's status for 1 of 5 residents (Resident #24) reviewed for accurate assessments. Residents Affected - Few The facility failed to ensure Resident #24's MDS accurately reflected the resident's falls. This failure could place residents at risk for not receiving needed services or receiving improper or incorrect care and services necessary for their physical, mental and psychosocial well-being. The findings include: Record review of Resident #24's face sheet reflected a [AGE] year-old male with an admission date of 8/15/2024. Resident #24 had diagnoses which included Displaced Intertrochanteric Fracture of Left Femur (Broken Hip), Unspecified Dementia (decline in mental abilities that affects daily life), Schizophrenia (chronic mental illness that affects how one thinks, feels, and behaves), Muscle Weakness, Difficulty in Walking, Unspecified Lack of Coordination, and Repeated Falls. Record review of Resident #24's Quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Resident #24's fall on 9/20/2024 was not reflected in section J, Health Conditions in the MDS. Section J1800 which asked Has the resident had any falls since admission/entry or reentry or the prior assessment on the quarterly comprehensive assessment, dated 11/12/2024, did not reflect any falls. Record review of Resident #24's nurse progress notes reflected documentation of a fall on 9/20/2024. It was documented that the nurse went into Resident's #24's room around 7 a.m. to administer as needed pain medication. Resident #24 reported to the nurse that he fell out of bed onto the floor about 30 minutes prior. Resident #24 reported he hit the right side of his head. Resident #24 also reported pain to his right hand and hip. The nurse assessed Resident #24 for injuries, and none were noted. Resident #24 was sent to the hospital for evaluation. Record review of Resident #24's incident report, dated 9/20/2024, reflected a fall was documented,. on 9/20/2024 Resident #24 informed a nurse he fell out of bed onto the floor about 30 minutes prior to notifying the nurse at 7 a.m., when she went to administer requested pain medication. Resident #24 stated he hit his head, and his right hand and hip hurt. The nurse assessed the resident for injuries, but none were noted . During an interview on 12/10/24 at 8:33 a.m., the DON said Resident #24 had a fall which occurred on 9/20/24 . During an interview on 12/11/24 at 3:00 p.m., the Clinical Reimbursement Coordinator stated she completed the MDS assessments. The Clinical Reimbursement Coordinator said falls were noted in section J of the MDS and if there was a fall with no significant change then it would be noted on the next MDS. This should be completed . During an interview on 12/11/24 at 3:03 p.m., the DON named the MDS Coordinator who was the same as the Clinical Reimbursement Coordinator as the person who completed the MDS assessments. The DON said he signed the MDS after being notified it was completed. 675079 Page 3 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0641 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, MDS Completion Accuracy and Timeliness, reflected the facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely. Also, that each facility must also utilize most updated Texas TAC rules for MDS accuracy. Residents Affected - Few 675079 Page 4 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for reviewed for 2 of 3 residents (Resident #47 and Resident #25) reviewed for resident assessments. The facility failed to update the PASRR Level 1 forms for Resident #47 and Resident #25 to indicate mental health illness. This failure could place residents at risk of not having their special needs assessed and met by the facility. Findings included: 1. Record review of Resident #47's admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had with diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls, major depressive disorder (persistently depressed mood), alcohol dependence, insomnia (persistent problem falling or staying asleep), mood disorder (different psychiatric conditions that cause changes in a person's emotional state), psychosis (a psychiatric condition that causes a person to lose touch with reality), adjustment disorder with depressed mood (mental health condition when someone has difficulty coping with major stressors or changes in life), quadriplegia (partial or total paralysis in all four limbs and the torso), and alcohol dependence with alcohol induced persisting dementia, (a condition that results from chronic alcohol consumption and the resulting brain damage). Continued record review revealed Resident #47's diagnosis of psychosis was dated from his admission 3/28/22. Record review of Resident #47's PASRR Level 1, dated 2/21/22,-section C0100 Mental illness Is there evidence or indication this is an individual that has a Mental Illness? and the answer was documented as No. Record review of Resident #47's Annual MDS, dated [DATE], Section I Active Diagnoses read in part: 15950. Psychotic Disorder (other than schizophrenia). 2. Record review of Resident #25's admission Record, dated 12/11/24, revealed a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses which included: delusional disorder (psychotic condition characterized by persistent false beliefs), obsessive-compulsive disorder (excessive thoughts that lead to repetitive behaviors), adjustment disorder with mixed anxiety and depressed mood (mental health condition that involves experiencing both symptoms of anxiety and depression), and major depressive disorder recurrent severe with psychotic symptoms (a serious mental illness that involves both depression and psychosis or loss of touch with reality). There was no diagnosis of dementia. Record review of Resident #25's PASRR Level 1 Screening, dated 8/19/2020, indicated .Mental illness .Is there evidence or an indicator this is an individual that has a Mental Illness .No 675079 Page 5 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #25's Annual MDS, dated [DATE], Section I Active Diagnoses read in part: 15900. Bipolar Disorder. 15950. Psychotic Disorder (other than schizophrenia). During an interview on 12/11/24 at 11:14 AM, with MDS Coordinator A who said she was not aware of Resident #25 and Resident #47's mental illness diagnoses from admission did not have primary diagnoses of dementia. She said she had worked at the facility for the last 4 years but had not ever completed any audits of previous PASSR Level 1 evaluations for accuracy, because she did not know she had to. MDS Coordinator A had not really used the 1012 form for Mental Illness before and did not know of any sister facilities that had completed them or used them. MDS Coordinator A said both Resident #25 and Resident #47 had potentially qualifying MI diagnoses and she would look at each of their PL-1's and complete a 1012 form for each of them. MDS Coordinator A said she used the RAI manual to complete MDS's and PASRR requirements as the policy and procedure she followed. Follow up interview with MDS Coordinator A on 12/11/24 at 11:53 AM, she said the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be the resident would not receive the necessary services they may qualified for. She provided copies of undated 1012 forms For Mental Illness/Dementia Resident Review for Resident #25 and Resident #47 . The MDS Coordinator A said she was unsure if Resident #25 and Resident #47 should have had an updated PASRR or if a form 1012 should have been completed for each of them. The MDS Coordinator A said that she was ultimately responsible for any PASRR updates. Interview with the Administrator on 12/11/24 at 1:08 PM, he said there was a Corporate MDS Coordinator who could provide oversight for MDS Coordinator A, but he was unsure what her name was and said he would provide her contact information. The Administrator said he would do some in-service education with MDS Coordinator A. The Administrator said he was unsure who conducted audits of PL-1's but he said he knew what a form 1012 was and when it should be used ,which was when a resident was later discovered to have a potentially qualifying MI diagnosis. The State Surveyor requested information for the Corporate MDS Coordinator but did not receive it prior to exit. When to Prepare: Form 1012 assists nursing facilities (NF ) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I (PL1 ) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed . 675079 Page 6 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. -The facility failed to label, and date left over food items stored in the walk-in cooler. -The facility failed to ensure dented cans were not stored together with undented cans. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination. The findings included: Initial kitchen observation on 12/09/24 at 8:40 AM revealed the following - (All food items were identified by the Dietary Manager) observation of the walk-in freezer in the kitchen revealed. -an open bag of chicken parties which was unlabeled and undated, -a half bag of chicken strips was un-labeled and undated. -3 full bags of chicken parties were unlabeled and undated. -chicken parties in a plastic bag were not sealed, were unlabeled and undated Observation of the dry goods storage revealed one 6 Ibs dented can of sliced apple and one 6.2 Ibs. of dented fancy tree beans. In an interview with the Dietary Manager, on 12/09/24 at 9:00 AM, she said the dented cans were supposed to be kept in her in her office for credit. She said she was sick and today 12/09/24 was her first day back. She said she expected all food items out of the original box\containers to be labeled and dated with a used by date. She said inappropriate food storage could lead to cross contamination and food poisoning. Record review of the facility's policy, dated May 2020, entitled Labeling and Dating Foods. Policy statement read in partGuideline: All foods stored will be properly labeled according to the following guidelines. Procedure: Date marking for refrigerated storage food items. 675079 Page 7 of 8 675079 12/11/2024 Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in - first out method of rotation. -Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in - first out method of rotation. -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. 675079 Page 8 of 8