Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the
risks, and participate in, his or her treatment which included the right to be informed in advance, by the
physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and
treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2
of 20 residents (Resident # 38, Resident #61) reviewed for resident rights .
Residents Affected - Some
The facility failed to obtain informed consent based on information of the benefits, risks, and options
available from Resident #38 prior to administering Sertraline, an antidepressant used to treat depression.
The facility failed to obtain informed consent based on information of the benefits, risks, and options
available from Resident #61 prior to administering Venlafaxine, an antidepressant used to treat depression.
This failure could place residents at risk of receiving medications without their prior knowledge or consent,
or that of their responsible party.
Findings include:
Record review of Record review of Resident #38's face sheet revealed admission date of 05/04/22 with
diagnoses of chronic embolism (a blood clot that has formed a scar on vein and does not allow blood flow),
Parkinson's disease (progressive disease of the nervous system), intellectual disabilities (affects the ability
to acquire knowledge and skills needed for independent living), seizures (sudden burst of electrical activity
in the brain), and psychosis (disorder causing delusions, hallucinations, agitation). She was [AGE] years of
age.
Record review of Resident #38's quarterly MDS, dated [DATE], indicated he had a BIMS score of 03, which
indicated he was severely cognitively impaired. The MDS also indicated Resident #38 was receiving
antidepression medications.
Record review of Resident #38's care plan indicated, in part: Focus: resident is currently using
antidepressant for depression. Goal: The resident will be free from discomfort or adverse reactions related
to antidepressant therapy through the review date. Intervention: Administer antidepressant medications as
ordered by physician. Monitor/document side effects and effectiveness every shift.
Record review of Resident #38's medication profile dated 07/09/23 indicated in part: Sertraline tablet 25
MG, give 1 tablet by mouth one time a day for depression.
(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 4
Event ID:
675722
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
675722
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Fort Stockton
501 N Sycamore
Fort Stockton, TX 79735
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)
F 0552
Record review of Resident #38's clinical records revealed no consent on file.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Record review of Resident #61's face sheet revealed admission date of 08/03/23 with
diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed
mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus (condition that effects the
way body processes blood sugar). She was [AGE] years of age.
Residents Affected - Some
Record review of Resident #61's admission MDS, dated [DATE], indicated she had a BIMS score of 10,
which indicated she was minimally cognitively impaired. The MDS also indicated Resident #61 was
diagnosed with major depressive disorder.
Record review of Resident #61's care plan indicated, in part: Focus: Resident has impaired cognitive
function or impaired thought processes related to BIMS of 10. Goal: The resident will be able to
communicate basic needs daily through the review date. Intervention: Administer medications as ordered.
Monitor/document for side effects and effectiveness.
Record review of Resident #61's medication profile dated 08/04/23 indicated in part: Venlafaxine capsule,
give 150 mg by mouth once a day for depression. Seroquel Tablet, give 25 mg by mouth two times a day for
mood disorder.
Record review of Resident #61's clinical records revealed no consent on file.
Interview on 10/05/2023 at 12:57pm, the ADON stated that the admitting nurses are responsible for
obtaining consents for medications from residents or resident representatives on admission. If it is a new
order, the nurse getting the order is responsible for obtaining consent. The ADON stated that the facility's
system of ensuring that consents were obtained properly was not effective which lead to the failure. ADON
stated that she was aware medication should not have been administered without obtaining consents first.
Interview on 10/05/2023 at 2:00pm, the Administrator stated that nurses were responsible for obtaining
consents on admission and upon receiving new orders. The Administrator stated that her expectations was
that all nursing staff would review all residents during the daily morning meetings and discuss new orders to
ensure proper consents were obtained.
Per Administrator, the facility has no policy specific to the consenting process.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675722
If continuation sheet
Page 2 of 4
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
675722
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Fort Stockton
501 N Sycamore
Fort Stockton, TX 79735
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview and record review the facility failed to provide pharmaceutical services,
including procedures that ensure the accurate administering of all drugs to meet the needs of the residents,
for 1 of 2 medication carts reviewed for pharmacy services, in that: .
The medication cart used for hall 100 had an insulin pen that had expired as indicated by the
manufacturers recommendations.
This failure could place residents at risk of receiving medications that were expired and not produce the
desired effect.
The findings were:
During an interview and observation on 10/03/23 at 04:30 PM the hall one treatment cart was inspected
with LVN A present. Inside the cart was one insulin pen with an open date of 08/27/2023 written on it. The
insulin pen instructions indicated Use within 28 days after initial use. LVN A said the insulin pen should
have been removed since it was expired and that she would remove it at this time. LVN A said as far as she
knew it was every nurses job to remove any expired medications from the medication cart whenever they
used it. LVN A said if a resident received and expired medication it could lead to a bad reaction or not the
desired effect.
During an interview on 10/05/23 11:45 AM the ADON said they would try to do weekly inspections of the
medication carts and remove any expired medications. The ADON said there was no one specifically
assigned to do that nor was it documented anywhere. The ADON said if a resident received an expired
medication, then there was a possibility, they would not receive the desired effect.
During an interview on 10/05/23 at 02:08 PM the Administrator was made aware of the expired insulin pen
observed in the medication cart. The Administrator said nursing staff and the DON were responsible for
monitoring the medication carts for expired medications and remove them. The Administrator said if a
resident received and expired medication it might not be as effective. The Administrator said she believed
the failure occurred because the staff failed to check the expiration date on the medications and removed
them.
Record review of policy titled Storage of Medications and dated August 2020 indicated in part:
Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or
without secure closures are immediately removed from inventory. Certain medications or package types
such as IV solutions multiple does injectable vials and blood sugar testing solutions and strips require an
expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity
and potency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675722
If continuation sheet
Page 3 of 4
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
675722
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/05/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Fort Stockton
501 N Sycamore
Fort Stockton, TX 79735
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and
biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication
storage compartments reviewed for labeling/storage of drugs and biologicals.
The facility failed to ensure stored discontinued controlled medications and biologicals were separately
locked and in a permanently affixed compartment kept in the DON's office.
These failures could place the facility at risk of drug diversion and access to medications.
Findings Include:
During an observation on 10/04/23 at 09:18 AM the DON's office door was observed to be unlocked, open,
unsupervised and no staff present.
During an observation and interview on 10/04/23 at 10:44 AM the discontinued controlled medication
storage was inspected with the DON present. The discontinued controlled medications were located in the
DON's office on a free standing book shelf. The DON said she kept the controlled medications in a small
safe that was stored in an unlocked cabinet. The cabinet nor the safe were permanently affixed to the wall
or floor. The DON said she had just moved into this office like 2 months ago. The DON said the second lock
was the office door and she kept it closed and locked when she was not in her office. The DON was made
aware of the observation of the door open and the office unsupervised. The DON said she was not aware
the door was left open and her office unattended and leaving the controlled medications behind one lock
instead of two. The DON said they would get the safe secured immediately by adding 2 locks and have it
affixed to the wall. The DON said if the controlled medications were not secured then someone could
possibly just walk out with medications. Inside the safe were multiple blister containers and bottles of
controlled medications.
During an interview on 10/05/23 at 02:05 PM the Administrator was made aware of the observation
mentioned above. The Administrator said it was the DON's and herself responsibility to make sure the
controlled medications were kept behind 2 locks and permanently affixed. The Administrator said someone
could walk away with the controlled medications if they were not secured. The Administrator said the failure
probably occurred because the DON had just moved to the new office and the controlled medications had
not been placed behind 2 locks and permanently affixed just yet.
Record review of the facility policy titled Storage of Controlled Substances and indicated in part:
Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject
to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and
other applicable laws and regulations. Schedule II thru V medications and other medications subject to
abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other
medications or per state regulations. Controlled substances remaining in the facility after the order has
been discontinued or the resident has been discharged are retained in the facility in a securely locked area
with restricted access until destroyed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675722
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the October 5, 2023 survey of Focused Care at Fort Stockton?
This was a inspection survey of Focused Care at Fort Stockton on October 5, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Focused Care at Fort Stockton on October 5, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.