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 (continued on next page) 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 Page 1 of 8 Event ID: 675079 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)