Health inspection·December 4, 2025

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. 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 develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (CNA A, CNA B, LVN C, CNA D, and LVN E) employees reviewed for disaster training requirements. CNA A, CNA B, LVN C, CNA D, and LVNE were not adequately trained in emergency preparedness training related to bomb threats. This failure could result in delayed or inappropriate response in the event of a bomb threat.The findings included:Resident #3Review of Resident #3's admission Record, dated 12/2/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including paraplegia, pressure ulcer to the sacral region, neuropathy and above the knee amputation of both legs. Resident #3 was discharged [DATE]. Review of Resident #3's Quarterly MDS, dated [DATE], indicatedHe had a BIMS score of 13 of 15 (indicating he was cognitively intact) and he showed no signs of delirium.He reported no symptoms of depression.There were no behaviors reported. Review of Resident #3's Care Plan, updated 6/11/25, documented:Resident had a behavior problem related to low frustration tolerance. Identified interventions included - Anticipate and meet the resident's needs;- if reasonable discuss the resident's behavior, explain/ reinforce why behavior was inappropriate and/or unacceptable to the resident. Review of Resident #3's Care Plan, updated 10/12/24 (previous visit), documented:Focus: The resident had the potential to be verbally aggressive (cursing, yelling at staff) related to ineffective coping skillsGoal: The resident will demonstrate effective coping skills through the review date.Interventions:- Administer medications as ordered;- Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.- When the resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation; if response is aggressive, staff walk calmly away, and approach later. Interview on 12/2/25 at 12:23 p.m. CNA A stated she was at the nurse's station between 8 a.m. and 8:15 a.m. and Resident #3 approached her. CNA A stated Resident #3 told her he received an eviction notice and wheeled away. CNA A said then Resident #3 rolled up to her laughing; CNA A asked why he was laughing and Resident #3 stated when he got out of here he would shoot up or bomb this shit hole. CNA A stated she was at a loss for words and said, oh, okay. CNA A said she waited for a statement like ‘just kidding' but Resident #3 did not say anything. CNA A said it was like Resident #3 was joking but not joking and there was no eye contact when he said it, like he was really thinking about it. CNA A stated the nurse next to her did not hear it. CNA A said she told her nurse about it and the nurse instructed her to report to the Administrator. CNA A said someone told the DON, the ADON, and the SSD and she told them what happened. CNA stated the Administration called the police and the police asked her if she wanted to press charges. CNA A stated she thought Resident #3 was very capable of following through with the threat if he was back on drugs. CNA A said she could see Resident #3 was fantasizing about it, daydreaming about it. CNA A stated she had no idea to ask where he would put it because it was the first time anyone said something like Residents Affected - Some Page 1 of 4 675751 675751 12/04/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that to her. CNA A stated the training she received on disaster preparedness was the computer training and it kind of run through what to do with a bomb threat. CNA A said the last time she received training on what to do in case of a bomb threat was when there was a suspicious package across the street, but the police told them to shelter in place. CNA A stated the facility went over the situation in the next town hall meeting, but it was just the facility did what they had to do, it was very quick and just covered the staff moved the residents to safety. CNA A stated if she answered the phone and someone said there was a bomb in the building she would give the phone to the nurse. CNA A said she would then tell the other nurse so they could get a hold of the DON or ADON. CNA A said she wouldn't even know what to do. CNA A stated she read the policy and passed it on to the next person. CNA A stated she did not remember what disaster training went over a bomb threat at this or any other facility she worked at previously; CNA A said she only knew the order of evacuation and what to do in case of a fire. CNA A stated she did not feel the facilities went over it as much as fire preparation. Interview on 12/2/25 at 1:27 p.m. CNA B stated if she answered the phone and someone said there was a bomb in the building the training she got was to not panic, notify whoever was around to notify authorities and call administration. CNA B said she was told to keep the caller talking and ask questions. CNA B said she did not want to ask the caller the location of the bomb because she did not want to trigger them. CNA B said she would ask the caller what they wanted, what their intentions were, and keep them on the line as long as possible, distracted. After prompting by surveyor, CNA B said she would listen for background noises to try and determine where they were calling from. CNA B said the last training she received on what to do in a bomb threat was the previous year in another facility. CNA B said she was not worried about if someone called in because it would come to her. Interview on 12/2/25 at 2:34 p.m. LVN C stated he never saw Resident #3 be physical but he would yell a lot and push residents in wheelchairs to the side of the hall so he could get through. LVN C described Resident #3 as me first, now type of resident. LVN C said the aides would report he cussed them out a lot, but LVN C never saw it. LVN C stated he answered the phones. LVN D said if someone told him there was a bomb in the building he would uhh. alert the DON, ADON, police department, and get everyone out of the building. LVN C stated if a resident said they wanted to blow up the building, LVN C would ask why and what he could do to make them not want to blow up the building. LVN C said he did not know what he would do. LVN C stated he probably got training for a bomb threat but forgot it. Interview on 12/2/25 at 3:22 p.m. CNA D stated she worked with Resident #3, she described him as always angry with the world. CNA D stated he told LVN E ‘how would you like it if I bombed this place', but it was to LVN E. CNA D said Resident #3 would blow up for no reason. CNA D said if someone told her there was a bomb in the building she would ask where it was. CNA D stated she believed Resident #3 would tell her. CNA D said there was no reason for Resident #3 to say he wanted to blow up the building. CNA D said if she answered the phone and someone said there was a bomb in the building she would call 9-1-1 from another phone and write to the nurse to go look for the bomb. CNA D said she was never in that situation. CNA D said she never had disaster training in any building she worked in, and she did not know who was supposed to go look for the bomb or who was responsible for getting the residents out of the building. CNA D admitted she did not know what she would do. Interview on 12/2/25 at 4:31 p.m. LVN E stated Resident #3's behavior depended on the day. LVN E said on the bad days, Resident #3 would flip out, throw things, refuse wound care, yell, complain about little things, and use rude hand gestures. LVN E stated the only threatening thing Resident #3 said was these bitches will get what's coming to them and then he would be all apologetic. LVN E denied Resident #3 said he would blow up the building to her. LVN E said if a resident told her they wanted to 675751 Page 2 of 4 675751 12/04/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blow up the building she would call 9-1-1 immediately and then call the DON, Administrator and SSD. LVN E said there was also a number at the nurse's station for the local psychiatric hospital. Interview on 12/3/25 at 9:44 a.m. LVN F stated she was sitting next to CNA A and Resident #3 when Resident #3 made the bomb threat. LVN F said she did not know how she did not hear it; LVN F said she could hear they were talking but not what they were talking about. LVN F knew the process for what to do if someone called in a bomb threat. Interview on 12/3/25 at 12:47 p.m. the VPO said in case of a bomb threat, he expected his staff to keep the caller on the phone for as long as possible and get as much information as possible. The VPO said he expected the staff to flag down someone else to initiate calls to the local authorities, the administration, and evacuate the area if possible. The VPO stated he expected staff to follow the directions of the Administration. The VPO stated what to do in case of a Bomb Threat should be in the Disaster Preparedness book, the book should be available to everyone, and the default place for it was usually the nurse's station. The VPO stated the minimum requirement for Disaster Preparedness training was annually, but he expected the staff to be in-serviced as things came up. The VPO stated he expected staff to debrief with the Administration and just make sure the residents were safe. The VPO stated there was real-life situation at the facility, but the police told the facility to just shelter-in-place. The VPO stated the facility did drills on what to do in a disaster, but it was usually fire drills. Interview on 12/3/25 at 2:13 p.m. the DON stated if someone called in a bomb threat her expectation was the staff keep the caller on the line for as long as possible the flag someone else down to notify the police department and the Administration. The DON stated she expected the staff to try and get as much information as possible like who was the caller, where was the bomb, what kind of bomb was it. After prompting the DON stated the staff needed to be listening for background noise. The DON stated hopefully the police department got there quickly. The DON said if they could find out where the bomb was the facility could evacuate that part of the facility threatened. The DON stated the facility trained the staff in bomb threats twice a year but since there was the bomb scare in August 2025 they try to do the training a little more often. Interview on 12/3/25 at 3:52 p.m. the SSD stated Resident #3 was ok when the Administration was in the building but after hours he would be disrespectful and yell at the staff, especially the aides. The SSD stated the aide came to her and said Resident #3 made a bomb threat, so she let the case managers and Administrator know. The SSD said the facility called the police department and the police officer did speak with Resident #3. The facility requested a mental health screening and the Resident #3 denied making the statement, and that it was just a joke to the mental health screener. The SSD said she thought the switch in Resident #3's behavior was triggered because he had to make payments to the facility to stay there. Interview on 12/4/25 at 11:44 a.m. the Administrator stated the facility in-serviced staff on what to do in case of a bomb threat. Interview on 12/4/25 at 12:45 p.m. the Administrator stated the facility had town hall meetings informing the staff what to do in case of a bomb threat and none of the staff came to the management and stated they were not sure what to do. Review of the in-service, dated 9/22/25, documented the DON in-serviced 36 staff on restraints (physical and chemical), sharps and hazardous chemicals, and Egress and disaster preparedness. Review of the in-service, dated 11/17/25, documented the DON in-serviced staff on the smoking policy and bomb threats: exact time and date, keep calm, keep talking, ask when and where, notify appropriate personnel. 33 staff attended. Review of the facility's Emergency Procedure on Bomb threats, undated, documented Utilize the Bomb Threat Telephone Checklist if telephone threats or warnings about bombs in the facility are received. Try to keep the caller on the phone if possible. A separate staff member will initiate the call to 9-1-1. Make the following announcement: Code Yellow. Assigned 675751 Page 3 of 4 675751 12/04/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff please report to (location) for instructions.Notify the following Executive Director and/or the highest ranking staff member on duty.Do not approach or touch a suspicious package/device. Immediately evacuate everyone away from such discoveries and immediately report all findings to the Executive Director.It is essential to coordinate all actions with law enforcement officials. If a suspected bomb is located within the building, the responsibility for investigation will be that of the law enforcement officials having jurisdiction over such matters.Telephone Procedure:Keep the caller on the line if possibleAsk the caller to repeat the message.Record every word spoken by the person making the call.Record the time the call was received and terminated.Ask the caller his/her nameIf the caller does not indicate the location of the bomb or detonation time, the person received the call should ask the caller to provide this information.It may be advisable to inform the caller that the building is occupied and that the detonation of a bomb could result in death or serious injury to many innocent people.Completed the Bomb Threat Telephone Procedure Checklist. There was no check list provided. 675751 Page 4 of 4