Health inspection·May 14, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 3 ) of 2 residents reviewed for allegations of abuse. The facility failed to report Resident #3 's allegation of abuse related to LNV C's alleged withholding of medication to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of abuse to the proper authorities at the facility. Findings Include: Record review of Resident #3's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of generalized anxiety, schizophrenia, and bipolar disorder. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating his cognition was intact. Record review of Resident #3's care plan dated 3/19/25 revealed a focus area for resident has a behavior problem r/t low frustration tolerance, bipolar disorder, Schizophrenia with interventions that included Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Record review of LVN C's facility's Disciplinary Action Record dated 3/25/25 revealed nurse observed speaking loud and harshly to [Resident #4]. [Resident #3] complained as well. It was a verbal warning signed by ADCO and team member signature was blank. During an interview on 5/13/25 at 11:10 am, Resident #3, who was AOx4, stated that he felt he was abused when LVN C had not wanted to administer his medication after he returned from the hospital and missed his evening dose. Resident #3 stated that he was asking for an inhaler, as he knew it was scheduled, though he could not recall experiencing symptoms at the time. Resident #3 stated that LVN C had told him it was past the scheduled hour window. Resident #3 stated that he contacted the Page 1 of 17 675751 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0609 Level of Harm - Minimal harm or potential for actual harm administrator and reported that he felt abused because of the situation . Resident #3 stated that he was later informed the facility had reached out and was waiting for the physician's approval, and that he received the inhaler shortly after. Resident #3 stated that LVN C was written up but refused to sign the corrective action. Resident #3 stated the facility responded by removing LVN C from his direct care, and that he felt safe afterward. Residents Affected - Few During an interview on 5/13/25 at 2:14 pm, LVN C stated that the facility had recently reassigned care on that hall from himself to another nurse due to Resident #3's repeated complaints and the facility's efforts to accommodate his preferences. LVN C stated an instance when Resident #3 returned from the hospital and requested medication that was scheduled for a later time. LVN C stated that Resident #3 became upset and agitated. LVN C stated that the medication in question was a breathing treatment, which required clearance from the doctor, and that Resident #3 was not presenting with respiratory symptoms. LVN C stated that the treatment was administered after his shift, during shift change. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that she had not received recent complaints regarding LVN C. The ADCO stated that there was a past incident involving Resident #4 and LVN C, which resulted in a corrective action/write-up that was not signed by LVN C. The ADCO stated she had not been present during the incident and referred such matters to administrative leadership. The ADCO stated that a few staff had commented on LVN C's harsh tone. She stated that LVN C was removed from Resident #3's care following the incident. During an interview on 5/13/25 at 4:23 pm, the DCO stated there had been an incident involving LVN C and Resident #3. The DCO stated the issue stemmed from an argument regarding medication administration after Resident #3 returned late from the hospital and requested his 7 or 8 p.m. medication, which LVN C allegedly had declined to administer. The DCO stated that the Administrator had notified her of the incident in which she texted the nurse practitioner regarding the matter to get further instruction. The DCO stated that LVN C was removed from caring for Resident #3 following the incident. The DCO stated that no complaints had been received about LVN C using inappropriate language. The DCO stated he was not suspended and that the action taken was a write-up for speaking loudly and harshly to the resident. The DCO stated she could not speak to administrative decisions and that further details would be handled by leadership. During an interview on 5/14/25 at 11:27 am, the Administrator stated that no recent complaints had been received regarding LVN C. She stated she had instructed LVN C to stop caring for Resident #3 after observing tension and hearing from Resident #3 that LVN C was not performing his duties. She stated that Resident #3 had texted and called her around 10:00-10:20 p.m. to report that LVN C refused to give him his high inhaler medication. She stated that she determined LVN C's shift had already ended and the medication window had been scheduled for 5:00 p.m. She stated that LVN C had explained the missed dose and told Resident #3 about the situation. She stated that she planned for the DCO to follow up with the physician. She stated that she did not consider the incident to be abuse and that Resident #3 later apologized. She stated that the incident was not reported as abuse because there were no staff corroborations and she concluded that it was a misunderstanding, influenced by Resident #3's history of misusing the term abuse. She stated that she did not suspend LVN C, as the incident occurred after his shift ended, and the intervention of removing him from Resident #3's care was completed prior to his next scheduled shift. Record review of the facility's Abuse policy dated 01/01/2023 revealed All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported 675751 Page 2 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0609 immediately or not later than 2 hours of alleged violation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675751 Page 3 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #4) of 3 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness (overall reduced strength throughout the body) and muscle wasting and atrophy, multiple sites (loss of muscle tissue in several areas, leading to weakness); other lack of coordination (trouble controlling body movements), scoliosis (an abnormal curve of the spine), and reduced mobility (difficulty walking or moving around independently); encephalopathy (a type of brain dysfunction caused by another illness or imbalance in the body), unspecified lack of coordination (difficulty moving smoothly due to problems in the brain or nervous system), and dysphagia in the oropharyngeal phase and unspecified (trouble swallowing food or liquids); profound intellectual disabilities (significant limitations in mental functioning and daily living skills), epilepsy, unspecified (a seizure disorder), cerebral palsy (a condition that affects muscle movement and coordination, often from birth), and hemiplegia, unspecified side (paralysis on one side of the body, though the side is not specified). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as moderately impaired under the cognitive skills for daily decision making. Record review of Resident #4's PASRR Level 1 Screening Summary dated 10/16/24 revealed a positive response for a known or suspected diagnosis of intellectual disability. Record review of Resident #4's PASRR Evaluation dated 10/17/24 revealed he was identified as having an intellectual disability and requires specialized services. Record review of Resident #4's PCSP dated 1/22/25 revealed IDT meeting was held on 01/22/2025. Attendees included the resident, the PASRR habilitation coordinator, a social worker, PTA, RD/PTA, and nursing facility representatives. The following NFSS were identified and confirmed: Durable Medical Equipment. The Comments summary revealed the resident will continue PASRR habilitation coordination services. The family expressed interest in obtaining a CMWC and mattress, which were delayed pending Medicaid activation. The Local Authority for IDD confirmed the selected specialized services. During an interview on 5/14/25 at 10:18 am, the CRC stated Resident #4 was admitted on [DATE]. The CRC stated he did not have access to all PCSPs on his end, only the most recent dated 5/5/25. The 675751 Page 4 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CRC stated an initial care plan meeting was held with participation from himself, rehabilitation, the director, activities, dietary, and the local PASRR Coordinator, along with Resident #4 and their family. The CRC stated the local PASRR Coordinator offered services including assistance from the State of Texas such as gate assistive devices, a car seat, and other miscellaneous items. The CRC stated the facility provided input regarding Resident #4's low-income status and explained that the current wheelchair had been used for an extended period. The CRC stated a customized wheelchair was offered and accepted by Resident #4 and their family. The CRC stated he contacted the local PASRR Coordinator by phone, and she agreed to send the January PCSP, as it was not accessible to him. The CRC stated the local PASRR Coordinator informed him that the January PCSP was pending due to Medicaid status, which had remained pending since admission. The CRC stated the wheelchair request remained pending and under state review. The CRC stated the PCSP must align with the completion of an NFSS form, which must be submitted by the administrator, physician, and director of rehabilitation. During an interview on 5/14/25 at 10:41 am, the DOR stated the NFSS for Resident #4 was initially submitted on 4/25/25 but was declined because an assessment was not associated with the submission. The DOR stated the physician's signature date could not precede the therapist's signature. The DOR stated the NFSS was resubmitted on 4/30/25 and was currently pending receipt and under state review. The DOR stated she was previously unaware of this status and understood that the state has up to 20 days to complete review. The DOR stated she was uncertain what type of wheelchair Resident #4 was currently using but confirmed it did not meet his needs. During an interview on 5/14/25 at 11:27 am, the Administrator stated she was familiar with the PASRR process and that the NFSS is completed by the DOR and should be submitted within two weeks. The Administrator stated that during the transition period in January, only four therapists were available, and some submissions may have been overlooked. The Administrator stated the current full-time DOR, began employment last month and had been addressing pending submissions. Record review of the facility's PASRR policy dated 11/2023 revealed Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-profession revealed: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures). 675751 Page 5 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 5 (Resident #4) residents reviewed for activities. Residents Affected - Few The facility failed to provide regular, individualized activities to Resident #4. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being. Findings included: Record review of Resident #4's face sheet dated 5/13/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: contracture of an unspecified joint (a joint that has become stiff and difficult to move) and contracture of muscle, unspecified site (a tightening of muscles that limits movement); generalized muscle weakness (overall reduced strength throughout the body) and muscle wasting and atrophy, multiple sites (loss of muscle tissue in several areas, leading to weakness); other lack of coordination (trouble controlling body movements), scoliosis (an abnormal curve of the spine), and reduced mobility (difficulty walking or moving around independently); encephalopathy (a type of brain dysfunction caused by another illness or imbalance in the body), unspecified lack of coordination (difficulty moving smoothly due to problems in the brain or nervous system), and dysphagia in the oropharyngeal phase and unspecified (trouble swallowing food or liquids); profound intellectual disabilities (significant limitations in mental functioning and daily living skills), epilepsy, unspecified (a seizure disorder), cerebral palsy (a condition that affects muscle movement and coordination, often from birth), and hemiplegia, unspecified side (paralysis on one side of the body, though the side is not specified). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed no BIMS score was noted but was marked as moderately impaired under the cognitive skills for daily decision making. Record review of Resident #4's care plan dated 10/16/24 revealed a focus area for attend activities of choice with interventions that included provide in room activities as needed and required. During an observation on 5/13/25 at 8:56 am, Resident #4 was observed in bed, nonverbal, and staring at the door. During an observation on 5/13/25 at 9:16 am, Resident #4 remained in bed, nonverbal, and was staring at the ceiling. During an observation on 5/13/25 at 10:41 am, Resident #4 was still in bed in the same position, continuing to stare at the ceiling. During an interview on 5/13/25 at 10:43 am, CNA A stated that Resident #4 was nonverbal. CNA A stated Resident #4 typically did not leave his room. She stated that she was not aware of any in-room activities provided to him and had only observed him in bed. She stated that Resident #4 had not been provided with any items for engagement and stated that activity provision was the responsibility of 675751 Page 6 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0679 the activities staff. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/14/25 at 12:42 pm, the Activities Director stated that Resident #4 did not have in-room activities provided and was unable to clarify the reason. She stated that Resident #4 did not have a radio or similar form of entertainment while in bed. She expressed uncertainty regarding the potential risks of limited stimulation and stated that she was not familiar with Resident #4's cognitive level. The Activities Director stated he enjoys listening to music and had not thought about getting him a stereo for his room to enjoy. Residents Affected - Few During an interview on 5/14/25 at 12:46 pm, the Administrator stated that Resident #4 participated in facility activities and was frequently out of bed. She stated that he attended events such as holiday parties for Mother's Day and St. Patrick's Day. She stated that the Activities Director provided in-room engagement such as hand painting and other creative tasks at bedside. Record review of the facility's Life Enrichment Activity Guidelines dated 04/2020 revealed The community will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities . 675751 Page 7 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 1 (Resident #7) of 5 residents reviewed for transfers. The facility failed to ensure Resident #7 had floor mat at bedside when in bed to prevent falls with injury that occurred on 05/12/2025. This failure could place residents at risk for falls or injuries. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things that aren't real due to brain-related illness; substance dependence in remission, indicating a past drug or alcohol problem that is currently under control; generalized anxiety disorder, which causes ongoing and excessive worry, and major depressive disorder, a condition involving long-lasting and severe sadness; unspecified lack of coordination, meaning he struggles with balance and movement control; generalized muscle weakness makes it harder for him to move, stand, or walk; rhabdomyolysis, a serious muscle condition where broken-down muscle fibers can damage the kidneys; mild cognitive impairment affects his memory and thinking skills, though not severely enough to be classified as dementia; stroke caused by a blood clot in the brain, which may have resulted in weakness or confusion; muscle wasting in both lower legs, meaning he has lost muscle tissue, making his legs weaker and thinner; lack of coordination, indicating further difficulties with controlled movements and balance. Record review of Resident #7's annual MDS assessment dated [DATE] revealed a no BIMS score (indicative of severe cognition impairment) noted and his was triggered for falls. Record review of Resident #7's care plan dated 5/7/25 revealed a focus area for history of falls that included interventions for low bed to decrease incidents of falls, fall mat at bedside when in bed. Record review of Resident #7's progress note dated 5/2/25 written by LVN B revealed [Resident #7] fell out of bed, landing on fall mat but got a 5cm laceration/bump to left forehead that is tender to touch. Cleansed laceration and pat dry, placed steri-strips. Denies any other c/o pain or discomfort. [Resident #7] moves leftt upper and lower ext. WNL. VS-123/61, 63, 18, 97.5, 97% on RA. Assisted back to bed x3 staff. Physician, DCO, ADCO, and Admin notified. Placed call to family, no answer, unable to leave message. Record review of Resident #7's local hospital Discharge summary dated [DATE] revealed diagnoses of traumatic hematoma of forehead and neck pain. No nre orders were noted and only instruction provided was to follow up with physician within 2-4 days. 675751 Page 8 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0689 Level of Harm - Actual harm Record review of Resident #7's CT Cervical Spine without contrast dated 5/2/25 revealed Clinical Information: Patient evaluated due to trauma. Findings: No fracture, dislocation, or prevertebral soft tissue swelling. Mild osteopenia (low bone density). Diffuse degenerative changes throughout cervical spine. Impression: Residents Affected - Few No fracture or dislocation. Degenerative spinal changes, especially at C5-C6, with narrowing in several nerve pathways (foramina) and central canal. Diffuse skeletal wear and tear. No major changes compared to the last scan on December 20, 2023. Record review of Resident #7's CT Brain/Head without contrast dated 5/2/25 revealed Clinical Information: Patient evaluated for trauma-related concerns. Findings: Moderate-sized anterior subcutaneous hematoma on the left of midline. No acute intracranial abnormalities (no stroke, fluid collection, mass, midline shift, or bleeding). Calcified changes in skull arteries. Mild generalized brain volume loss for age. Chronic small vessel ischemic disease. Old strokes noted in left frontoparietal region and right premotor frontal cortex. Small old infarcts seen in the left basal ganglia. Impression: Moderate anterior subcutaneous hematoma (left of midline). No acute intracranial abnormality. Mild generalized volume loss (age-related). Chronic ischemic changes consistent with age. During an observation and interview on 5/13/25 at 8:57 am, Resident #7 was observed to have a black eye and a hematoma on his left eyebrow . He was AOx2 and stated he had fallen in the facility but could not recall when or where the fall occurred. He reported that he was trying to go to the restroom when he fell. It was noted that his bed was at lowest position and no floor mat was noted at bedside. During an interview on 5/13/25 at 10:43 am, CNA A stated that Resident #7 had been moved to his current room the previous day, with the transfer occurring on Monday (5/12/25). CNA A stated that Resident #7 was a fall risk and should have had a floor mat placed at the bedside. She stated she was unsure why the mat had not been placed and stated she had reported the issue to the nurse, who stated she was looking for it. During an interview on 5/13/25 at 1:32 pm, LVN B stated that Resident #7 fell during her shift at approximately 10:30 AM. LVN B stated she was notified by CNAs while at the nurse ' s station. LVN B stated that upon arriving, she found Resident #7 on the floor mat, with his head off the mat and the left side of his face on the floor. LVN B stated the fall was unwitnessed. LVN B stated Resident #7 sustained a laceration to the left forehead. LVN B stated Resident #7 reported pain to the head and later stated his neck was hurting. LVN B stated Resident #7 is on aspirin and Eliquis. LVN B stated she assessed Resident #7, checked his vitals, turned him on the mat, asked about pain, and assisted him back to bed. LVN B stated neuro checks were initiated. LVN B stated she reported the fall to the DCO and ADCO and faxed a report to the physician. LVN B stated no new orders were received. LVN B stated Resident #7 was eventually sent out to the hospital the same day and returned after her shift without sutures or new orders. During an interview on 5/13/25 at 2:31 pm, CNA C stated she had just completed changing and repositioning Resident #7, placing the bed in a low position with the fall mat in place on day of the incident (5/2/25). CNA C stated that while conducting rounds, she heard Resident #7 calling for help. CNA C stated that upon responding, she found Resident #7 on his stomach, with his left side and face on the floor and his head partially under the bed frame. CNA C stated she lifted the bed and spoke to Resident #7 while calling for additional assistance. CNA C stated she notified the nurse, LVN B, that Resident #7 was bleeding from the head. CNA C stated she extended his legs out with permission 675751 Page 9 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0689 Level of Harm - Actual harm Residents Affected - Few from LVN B. CNA C stated she noted visible swelling and a bulge at the injury site. CNA C stated the CNAs transferred Resident #7 to bed with LVN B ' s direction. CNA C stated Resident #7 did not initially express pain but later began verbalizing head pain. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that fall prevention measures included keeping the bed in the lowest position, placing a fall mat at the bedside, and ensuring the call light was within reach. The ADCO stated that charge nurses and aides conducted routine rounds, and department heads completed morning room checks. The ADCO stated that failure to have floor mat at bedside, Resident #7 was at risk for injury related to falls. During an interview on 5/13/25 at 4:23 pm, the DCO stated that the facility's fall prevention measures included bed positioning, floor mats, and accessible call lights. The DCO stated that staff completed regular rounds and room checks to ensure fall preventions were followed and stated that Resident #7 was at risk for fall-related injury due to not having floor mat at bedside. The DCO stated staff received training regarding fall precautions on a daily basis. DCO stated that Resident #7 was a known frequent faller. DCO stated that fall precautions in place included use of a low bed, floor mat, and frequent rounding by CNAs, housekeeping, and nurses. DCO stated the mat is placed when Resident #7 is in bed. DCO stated she walks the halls daily to ensure fall prevention practices are being followed. DCO stated she attempts to review fall precautions at least monthly. DCO stated the identified risk was injury related to falls. DCO stated Resident #7 was moved to a different hallway where a bed was available closer to the nurses station for increased monitoring. During an interview on 5/13/25 at 5:56 pm, Dr. stated he had been notified about Resident #7 ' s fall on May 2, 2025, by fax, phone call, or text, though he was unable to recall the exact method due to the volume of communications from the facility. Dr. stated that when a resident falls, the standard protocol is to assess whether they are stable. Dr. stated that if the bleeding has stopped and the resident remains conscious, the recommendation is typically to monitor. Dr. stated that if the resident is unconscious or the bleeding is persistent, immediate transfer to the hospital is warranted. Dr. stated that Resident #7 sustained a laceration to the head and had complained of pain. Dr. stated steri-strips were reportedly changed three times prior to Resident #7 being sent out. Dr. stated that in cases involving anticoagulant use, such as Eliquis, taken the morning of the fall, a resident with worsening or significant pain would generally be expected to be transferred within a few hours. Dr. stated that judgment is based on the presence or absence of concerning symptoms at the time. Dr. stated that Resident #7 underwent CT scans of the brain and cervical spine while at the hospital. Dr. stated the brain scan showed a subcutaneous hematoma without evidence of intracranial bleeding. Dr. stated the cervical spine scan did not show fractures or dislocation but did show chronic osteoarthritis, which may contribute to balance issues. Dr. stated laboratory results did not indicate anemia, infection, or kidney dysfunction, and Keppra levels were not in the toxic range. Dr. stated that Resident #7 is at high risk for falls and should be monitored closely. Dr. stated that floor mats can sometimes help but may also pose a tripping hazard depending on the resident ' s behavior. Dr. stated the use of such interventions should be evaluated individually. Dr. stated that there were no serious findings from the hospital evaluation and that the injuries appeared to be superficial, with no immediate complications identified. During an interview on 5/14/25 at 11:27 am, The Administrator stated she received a report that Resident #7 was being provided a new mattress because the previous one was soiled. The Administrator stated all staff to include CNAs, nurses, and management were responsible for ensuring fall prevention measures were in place and followed during their daily rounds. The Administrator stated all staff received training on fall prevention at least monthly by the DOC. The Administrator stated potential 675751 Page 10 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0689 risk for not having floor mat at bedside when in bed could be fall with injury. Level of Harm - Actual harm Record review of the facility's Incident and Accident policy dated 03/01/2017 revealed 11. A fall prevention program will be initiated. The program will be reviewed with any subsequent falls. All programs will be documented in the plan of care and updated with each new fall. Residents Affected - Few 675751 Page 11 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. This failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings included: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor coordination, which affects her ability to move steadily and may lead to clumsiness or difficulty walking; aphasia, a condition that impacts her ability to speak and comprehend language, often linked to brain damage; anxiety and psychosis, which can include confusion, hallucinations, or delusions, along with schizoaffective disorder, a condition involving both mood swings and symptoms similar to schizophrenia; gastronomy status, she receives nutrition through a feeding tube placed directly int her stomach. Record review of Resident #6's annual MDS assessment dated [DATE] revealed she did not have a BIMS score but her cognitive skills for daily decision was marked as severely impaired. The nutritional status was marked as her receiving feeding tube. Record review of Resident #6's care plan was dated 5/8/25 revealed a focus area for requires tube feedings related to dysphagia/swallowing problem with interventions that included resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. Record review of Resident #6's physician order dated 4/18/2018 revealed elevate head of bed at least 30 degrees while administering formula/water/ medications and for at least 30 minutes following administration continuous. During an observation on 5/13/25 at 9:10 am, Resident #6 was observed in bed with the head of bed elevated to 30 degrees, she was nonverbal. However, she was positioned halfway down the mattress with her torso and upper body lying flat. A continuous tube feeding was noted at 32 ml/hr. No signs of distress were observed. During an interview on 5/13/25 at 9:30 am, LVN B stated that Resident #6 had told her she was elevated at approximately 10 degrees. LVN B stated that the resident was elevated to mid-rails to prevent her from falling. She stated that the resident could not get out of bed but was able to turn. She stated there was a risk of aspiration but believed the current elevation was sufficient given the 675751 Page 12 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's fall risk. She stated that CNAs and nursing staff were responsible during rounds. She could not recall the last time she received training specific to G-tube monitoring related to positioning. During an interview on 5/13/25 at 3:07 pm, the ADCO stated that facility policy requires residents with G-tubes to remain at approximately a 45-degree angle with the head elevated to reduce the risk of aspiration. She stated that this responsibility falls on aides and nurses, and that compliance is reviewed twice a year during rounds. During an interview on 5/13/25 at 4:23 pm, the DCO stated that Resident #6 was on continuous tube feeding and should not be laid flat. She stated that aides and charge nurses were responsible for maintaining the resident's elevation at a minimum of 45 degrees, ensuring that both the head and upper body were elevated, not just the bed. She stated that the resident had a tendency to slide down in bed and should be repositioned regularly to maintain proper alignment . She stated that the risk associated with improper positioning was aspiration and added that training on this topic had not been provided recently. During an interview on 5/14/25 at 11:27 am, the Administrator stated that some residents, including Resident #6, tend to slide down in bed despite repositioning efforts. She stated that residents should still be repositioned at least every two hours. She stated that this task can be performed by CNAs, nurses, or administrative staff. She also stated that training on positioning is included in monthly town hall meetings. Record review of the facility's Administration of Medications via Enteral policy dated 04/2020 revealed there is no direct mention in the provided policy text of residents needing to be positioned at a 30- or 45-degree angle during enteral medication administration or feeding. 675751 Page 13 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #7) of 6 residents reviewed for accuracy of records. The facility failed to ensure LVN C documented Resident #7's return from the hospital. This failure could have placed residents at risk for inaccurate medical records. Findings included: Record review of Resident #7's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: cerebrovascular disease, meaning he has problems with blood flow in the brain, which can lead to strokes or damage to brain tissue; seizures, which are sudden episodes of uncontrolled electrical activity in the brain that can cause shaking or confusion; psychotic disorder caused by a medical condition, meaning he may have false beliefs or see things that aren't real due to brain-related illness; substance dependence in remission, indicating a past drug or alcohol problem that is currently under control; generalized anxiety disorder, which causes ongoing and excessive worry, and major depressive disorder, a condition involving long-lasting and severe sadness; unspecified lack of coordination, meaning he struggles with balance and movement control; generalized muscle weakness makes it harder for him to move, stand, or walk; rhabdomyolysis, a serious muscle condition where broken-down muscle fibers can damage the kidneys; mild cognitive impairment affects his memory and thinking skills, though not severely enough to be classified as dementia; stroke caused by a blood clot in the brain, which may have resulted in weakness or confusion; muscle wasting in both lower legs, meaning he has lost muscle tissue, making his legs weaker and thinner; lack of coordination, indicating further difficulties with controlled movements and balance. Record review of Resident #7's annual MDS assessment dated [DATE] revealed a no BIMS score noted. Record review of Resident #7's care plan dated 5/7/25 revealed a focus area for history of falls that included interventions for low bed to decrease incidents of falls, fall mat at bedside when in bed. Record review of Resident #7's progress note dated 5/2/25 written by LVN B revealed Res. fell out of bed, landing on fall mat but got a 5cm laceration/bump to Lt forehead that is tender to touch. Cleansed laceration and pat dry, placed steri-strips. Denies any other c/o pain or discomfort. Res. moves Lt upper and lower ext. WNL. VS-123/61,63,18,97.5,97% ORA. Assisted back to bed x3 staff. Physician, DCO, ADCO, Admin notified. Record review of Resident #7's progress notes revealed no documentation regarding Resident #7 return from the hospital. During an observation and interview on 5/13/25 at 8:57 am, Resident #7 was observed to have a black eye and a hematoma on his left eyebrow. He was AOx2 and stated he had fallen in the facility but could not recall when or where the fall occurred. He reported that he was trying to go to the restroom when he fell. It was noted that his bed was at lowest position and no floor mat was noted at 675751 Page 14 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0842 bedside. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/13/25 at 1:32 pm, LVN B stated that Resident #7 fell during her shift at approximately 10:30 a.m. LVN B stated she was notified by CNAs while at the nurse's station. LVN B stated that upon arrival, she found Resident #7 on the floor mat with his head off the mat and the left side of his face on the floor. LVN B stated the fall was unwitnessed. LVN B stated Resident #7 sustained a laceration to the left forehead. LVN B stated he reported head pain and later stated his neck was hurting. LVN B stated he was on aspirin and Eliquis. LVN B stated she assessed Resident #7, checked vitals, turned him on the mat, asked about pain, and assisted him back to bed. LVN B stated she initiated neuro checks. LVN B stated she reported the fall to the DON, ADON, and faxed a report to the physician. LVN B stated no new orders were received. LVN B stated she attempted to notify the resident's family member , who typically did not answer and did not respond that day. LVN B stated she created the fall note at 1:18 p.m. LVN B stated Resident #7 was sent to the hospital the same day and returned after her shift without sutures or new orders. Residents Affected - Few During an interview on 5/13/25 at 2:14 pm, LVN C stated he was not present during the fall, which occurred during the morning shift. LVN C stated Resident #7 returned during his shift. LVN C stated he was with another patient and did not receive a report or verbal notification of the resident's return. LVN C stated the resident was brought in with paperwork and had a bandage over his eye. LVN C stated Resident #7 denied pain. LVN C stated he was supposed to complete a readmission assessment but likely did not due to a busy shift and communication issues. LVN C stated he understood the expectation was to complete the assessment and that potential risk for lack of documentation could be information being overlooked during high workload periods. During an interview on 5/13/25 at 3:07 pm, the ADCO stated there was no documentation of return time, new orders, or vitals for Resident #7. The ADCO stated staff were required to document these elements. The ADCO stated training was provided monthly and as needed. The ADCO stated leadership reviewed 24-hour reports and compared them with shift reports daily. The ADCO stated some nurses needed improvement, which could impact continuity of care. During an interview on 5/13/25 at 4:23 pm, The DCO stated nurses were expected to document upon a resident's return from the hospital, including any new orders and interventions performed at the hospital. The DCO stated she referred to the 24-hour report process. The DCO stated LVN C failed to chart when Resident #7 returned, and she noticed this the day of the interview. The DCO stated the risk of failing to document was that staff would not be aware of the resident's current condition. The DCO stated quarterly training was conducted to reinforce documentation expectations. The DCO stated the facility did not have a policy on accuracy of documentation. During an interview on 5/14/25 at 11:27 am, the Administrator stated staff were expected to document events as they occurred. The Administrator stated the Director of Clinical Operations had access to the 24-hour report and was expected to ensure follow-through and monitoring. The Administrator stated failure to document accurately could impact continuity of care. 675751 Page 15 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #6) residents reviewed for infection control. Residents Affected - Some The facility failed to ensure Resident #6 had a contact isolation on her door alerting visitors she was in isolation related to shingles. This failure could place residents at risk of cross contamination which could result infections or illness. Findings include: Record review of Resident #6's face sheet dated 5/13/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: seizures, including those caused by fever, and has episodes of uncontrolled body shaking without a clearly identified cause; poor coordination, which affects her ability to move steadily and may lead to clumsiness or difficulty walking; aphasia, a condition that impacts her ability to speak and comprehend language, often linked to brain damage; anxiety and psychosis, which can include confusion, hallucinations, or delusions, along with schizoaffective disorder, a condition involving both mood swings and symptoms similar to schizophrenia. Record review of Resident #6's annual MDS assessment dated [DATE] revealed she did not have a BIMS score but her cognitive skills for daily decision was marked as severely impaired. Record review of Resident #6's care plan dated 5/8/25 revealed a focus area for current skin concerns: rash to left and middle forehead; identified as shingles 5/8/25 - placed on isolation. Record review of Resident #6's physician order dated 5/8/25 revealed Valtrex oral tablet 1GM, give 1 tablet via peg-tube two times a day for shingles. Record review of Resident #6's progress note dated 5/8/25 written by DCO revealed [Resident #6] moved to isolation at this time. During an observation on 5/13/25 at 9:10 am, Resident #6 was noted to have PPE located outside of her room, but there was no signage posted indicating that she was under isolation precautions. During an interview on 5/13/25 at 9:30 am, LVN B stated that Resident #6 had been placed in isolation the previous week due to blisters on her forehead, which were identified as shingles. She stated that the resident was under contact precautions but there was no sign posted at the door to alert visitors or staff. She stated that she had noticed the missing signage but had not reported it to anyone. She stated that nursing administration would have been responsible for ensuring signage was posted. She stated that the lack of signage posed a risk, as visitors could unknowingly enter the room without PPE, potentially exposing themselves to infection. She stated that lab technicians and X-ray staff typically arrived in the early morning and reported to the charge nurse, who would then escort them to the resident's room. 675751 Page 16 of 17 675751 05/14/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/13/25 at 3:07 pm, the ADCO stated that she served as the infection preventionist nurse and that Resident #6 had been on contact isolation for shingles since the previous Thursday. She stated that there should have been signage on the door and noted that the resident had been moved late Thursday. She stated that she had not yet completed rounds in that area. She stated that the absence of signage posed a risk of transmission and cross-contamination. Residents Affected - Some During an interview on 5/13/25 at 4:23 pm, the DCO stated that Resident #6 was on isolation precautions for shingles and should have had appropriate signage and PPE setup outside her room. She stated that the ADCO was responsible for ensuring that isolation precautions were implemented. She stated that all direct care staff were expected to follow enhanced barrier precautions, including the use of gowns and gloves during activities such as dressing and perineal care. She identified the risk as potential transmission of infection. During an interview on 5/14/25 at 11:27 am, the Administrator stated that Resident #6 was in isolation for shingles. She stated that signage was posted on the door and that PPE was in place. She stated that the ADCO was responsible for monitoring compliance with isolation protocols. She stated that infection control training was conducted upon hire, monthly, and as needed. She identified contact transmission as the main risk . 675751 Page 17 of 17