Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 that residents received treatment and
care in accordance with professional standards of practice, the comprehensive person-centered care plan,
and the residents' choices, for 1 Resident (#1) of 5 residents whose care was reviewed, in that:
Residents Affected - Some
The facility failed to complete weekly skin assessments from 07/16/2024 to 09/23/2024 on Resident #1 at a
minimum of every 7 days per facility policy.
The facility failed to assess and provide treatment on 09/23/2024 when there were no orders for Edema on
bilateral lower legs for Resident #1 observed with seeping serosanguinous fluid.
This failure could place residents for not being provided with adequate care and treatment and place them
at risk for skin breakdown, infection, pain, and a decline in health.
The findings included:
Record review of Resident's #1 admission Record dated 09/19/2024 reflected a [AGE] year-old male,
admitted to the facility on [DATE]. Resident #1's diagnoses included Paranoid Schizophrenia (a disorder
that affects a person's ability to think, feel, and behave clearly), Type II Diabetes Mellitus with Diabetic
Peripheral Angiopathy (high blood sugar with decreased blood flow to the lower legs), and need for
assistance with personal care.
Record review of Resident #1's Quarterly MDS (Minimum Data Set) assessment, dated 07/19/2024,
reflected Resident #1 had a BIMS score of 15 (cognitively intact). Resident #1 was at risk for developing
pressure ulcers/injuries.
Record review of Resident #1's Comprehensive Care Plan, dated as initiated on 09/19/2024, reflected:
Focus: Resident tends to sign out and leave facility often. Resident is own representative and chooses to
leave the facility.
Interventions: Will assess resident on return from out on pass.
In an interview and observation on 09/23/2024 at 3:30 pm, revealed Resident #1 was sitting out on the front
porch in his wheelchair. Pitting edema (occurs when excess fluid builds up in the body, causing swelling;
when pressure is applied to the swollen area, a pit, or indentation, will remain) was noted to bilateral lower
extremities and his left leg was seeping serosanguinous fluid. Resident #1
(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 7
Event ID:
675985
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
said he has eczema (dry skin) and complained of itching and was observed scratching his genital area and
legs. The resident stated he took a bath this morning but did not know if a skin assessment had been
completed. Resident #1 was agreeable to a skin assessment with the surveyor and wound care nurse.
In an interview and observation of Resident #1's skin assessment with the wound care nurse, on
09/23/2024 at 3:40 pm, the wound care nurse stated it had been a while since his last skin assessment.
The wound care nurse said Resident #1's skin assessment day was on Tuesday, and he was usually on
pass and not in the building so his skin was not assessed for that week. When asked wound care nurse if
Resident #1's skin was assessed when he returns from pass, she said no. Observation of the resident
agreed skin assessment was completed in the resident's room and revealed the resident had dry scaled
skin across his abdomen, he had multiple small, scabbed areas bilaterally on his thighs and groin area, and
pitting edema to lower legs with serosanguinous fluid weeping on left lower leg. When Resident #1 laid
down on the bed for the skin assessment, Surveyor observed red serosanguinous fluid transferred on his
sheet.
A record review of Resident #1's weekly skin assessments, reflected no skin assessments were completed
from 07/16/2024 to 09/23/2024 as resident was on pass and out of the facility on his scheduled skin
assessment day.
A record review of Resident #1's progress notes, reviewed from 07/16/2024 to 09/23/2024 reflected no
documentation regarding skin assessments or weeping edema.
A record review of Resident #1's physician orders summary, dated 09/19/2024 reflected no orders for
treatment of his pitting edema or for assessing the edema.
In an interview on 09/24/2024 at 2:30 pm, the DON who said Resident #1 was competent and was his own
responsible party. She said Resident #1 will let the nurses know if he has a problem concerning his skin.
The DON said if a resident was not in the facility on their scheduled skin assessment day, the resident
should be evaluated when they return to the facility. She said Resident #1's physician ordered Nystatin for
his skin on 09/23/2024 and was to elevate his legs when sitting/sleeping for his edema.
In an interview on 09/25/2025 at 9:30 am, the Administrator who said skin assessments should be
completed weekly or when the resident returns to the facility. She said failure to complete weekly skin
assessments had the potential of a resident not being treated for skin issues or a pressure injury.
Record review of the facility policy Skin Management: Prevention and Treatment of Wounds, dated as last
revised 10/06/2022, revealed the following [in part]:
Policy: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure
injures, diabetic ulcers, arterial ulcers, and skin wounds.
Procedure: General Guidelines: Skin assessments will be documented at a minimum of every 7 days on a
Weekly Skin Assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 2 of 7
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 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
interview and record review, the facility failed to maintain clinical records in accordance with accepted
professional standards and practices that are complete and accurately documented for 1 of 5 residents
(Resident #1) reviewed for signing self in and out of the facility.
The facility failed to ensure Resident #1 signed in and out of the facility when he left for pass. Resident #1
failed to sign out of the facility on 08/08/2024 and 08/17/2024. He failed to sign back into the facility after
being out on pass on 08/02/2024, 08/05/2024, 08/11/2024, 08/20/2024, 08/30/2024, 09/01/2024,
09/04/2024, 09/06/2024, and 09/19/2024.
This failure could place residents for not being provided with adequate care and treatment when signed out
of the facility and evaluated when residents return to the facility.
Findings included:
Record review of Resident's #1 admission Record dated 09/19/2024 reflected a [AGE] year-old male,
admitted to the facility on [DATE]. Resident #1's diagnoses included Paranoid Schizophrenia (a disorder
that affects a person's ability to think, feel, and behave clearly), Type II Diabetes Mellitus with Diabetic
Peripheral Angiopathy (high blood sugar with decreased blood flow to the lower legs), and need for
assistance with personal care.
Record review of Resident #1's Quarterly MDS (Minimum Data Set) assessment, dated 07/19/2024,
reflected Resident #1 had a BIMS score of 15 (cognitively intact).
Record review of Resident #1's Comprehensive Care Plan, dated as initiated on 09/19/2024, reflected:
Focus: Resident tends to sign out and leave facility often. Resident is own representative and chooses to
leave the facility.
Interventions: Will assess resident on return from out on pass.
A record review of Resident #1's physician orders summary, dated 09/19/2024 reflected the order May go
out on therapeutic pass with medications, with a start date of 12/01/2022.
In an interview on 09/19/2024 at 4:37 pm. the Medical Director who said Resident #1 was competent and
frequently signs himself out of the facility when he wants to as he cannot be forced to stay in the facility.
A record review of the document Release of Responsibility for Leave of Absence for Resident #1 for the
months of August and September 2024 reflected in the Out on Leave portion, the resident was inconsistent
with signing himself out of the facility. In the Return for Leave portion, it was blank. Resident #1 failed to
sign out of the facility on 08/08/2024 and 08/17/2024. He failed to sign back into the facility after being out
on pass on 08/02/2024, 08/05/2024, 08/11/2024, 08/20/2024, 08/30/2024, 09/01/2024, 09/04/2024,
09/06/2024, and 09/19/2024.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 3 of 7
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 09/24/2024 at 1:45 pm, the Administrator who said residents should sign out of the
facility and sign back in when they return to the facility. She said it was the Residents responsibility to sign
themselves in and out of the facility and the staff was to remind them by asking them if they had signed out
or in. She stated if a nurse knows they are going out of the facility they should document that they are
signing out. She stated there was usually someone at the entrance of the building to see who went in and
out, but there was not always someone there. She said Resident #1 was not compliant with signing himself
in and out consistently.
In an interview with Resident #1 on 09/23/2024 at 3:30 pm, stated he came back to the facility last night. He
stated he does not always sign out when he leaves and comes back to the facility.
In an interview on 09/25/2024 at 9:15 am, the Administrator who said a potential negative outcome of a
resident not signing out would be the resident could be out of the facility longer than they know, and the
resident could be out of the facility and they do not know it.
A record review of the admission Agreement, not dated, under Frequently Asked Questions revealed the
following [in part]:
Leaving the Community: You may leave the community with a family member or friend during the day,
provided you have prior permission from your doctor. For overnight or longer periods, permission must be
obtained from your physician and proper insurance coverage must be checked beforehand. It is essential
that you inform the charge nurse or supervisor whenever you are going to be leaving the premises, and it is
also important that you notify him or her when you will be returning. The required procedure is to sign in
and out when coming and going.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 4 of 7
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 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 to help prevent the
development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #2)
reviewed for infection control practices, in that:
Residents Affected - Few
CNA A and Hospitality Aid B failed to perform proper hand hygiene after glove changes while providing
incontinence care to Resident #2 on 09/19/2024.
This failure could place residents at risk for the spread of infection.
The findings included:
Record review of Resident #2's admission Record, dated 09/09/2024, reflected a [AGE] year-old male, with
the latest admission date of 07/08/2024. Diagnoses included cerebral infarction (stroke) and need for
assistance with personal care.
Record review of Resident #2's Comprehensive Care Plan, dated as last revised on 09/11/2024 reflected:
Focus: I have an ADL self-care performance deficit related to stroke. Interventions: Toilet use - the Resident
is total dependent to toiler with two-person physical assist.
In an observation of incontinence care performed by CNA A and Hospitality Aid B for Resident #2 on
09/19/2024 at 11:24 am, revealed CNA A and Hospitality Aid B performed hand hygiene and put on gloves.
They removed Resident #2's brief that was soiled with feces. CNA A wiped the resident's urethral area in a
circular motion, washed the perineal area including the penis, scrotum, and inner thighs, and cleaned his
buttocks and anal area. CNA A and Hospitality Aid B changed gloves but failed to perform hand hygiene
before placing a new brief on Resident # 2. CNA A and Hospitality Aid B removed their gloves and
performed hand hygiene before leaving the room.
In an interview on 09/19/2024 at 11:45 am, CNA A and Hospitality Aid B said they should have performed
hand hygiene between gloves changes. They said they were both nervous and forgot. They said they had
recently passed a competency check and had completed an in-service on hand hygiene. Hospitality Aid B
said she just graduated and was testing for CNA certification soon. They said failure to complete hand
hygiene between glove changes could possibly lead to infection.
In an interview on 09/19/2024 at 11:50 am, the DON who said it was her expectation that hand hygiene to
be performed after every glove change. She was not sure why the failure occurred. The DON said failure to
perform hand hygiene between glove changes could lead to infection.
Record review of the facility policy Hand Hygiene, dated as last revised 10/24/2022 reflected the following
[in part]:
Policy: Hand hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a
general term that describes hand washing using soap and water or the use of alcohol-based hand rub
(ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands.
1.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 5 of 7
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 0880
You should always perform hand hygiene: *before applying and after removing personal protective
equipment (e.g. gloves, gown, mask, face shield/goggles.
Level of Harm - Minimal harm
or potential for actual harm
2.
Residents Affected - Few
You must perform hand hygiene after contact with bodily fluids, such as urine and blood.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 6 of 7
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
675985
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Midland
2000 N Main
Midland, TX 79705
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary
comfortable, environment for residents, staff, and the public for 6 of 6 hallways reviewed, including the
dining room and kitchen for physical environment.
The facility failed to ensure the floors were free of dirt and crumbs in the 6 hallways, dining room, and the
kitchen on 09/19/2024 and 09/24/2024 that had dirt and food crumbs along the walls at the intersection
between the floor and wall.
This failure could the residents by placing them at risk for diminished quality of life due to the lack of a
well-kept environment.
Findings included:
In an observation of the facility on 09/19/2024 at 11:00 am, the floors in each of the 6 hallways had dirt and
food crumbs along the walls at the baseboards. In the dining room, the floors were soiled and dirt and food
crumbs along the walls at the baseboards.
In an observation of the facility on 09/24/2024 at 11:20 am, the floors in each of the 6 hallways had dirt and
food crumbs along the walls at the baseboards. In the dining room, the floors were soiled and dirt and food
crumbs along the walls at the baseboards.
In an interview with the Administrator on 09/24/2024 at 4:00 pm, who stated it was her expectation for floors
to be cleaned. She said they have a new housekeeping director and new staff and were working on
improving the floors.
In an interview with the Administrator on 09/25/2024 at 9:15 am, who said potential negative outcomes of
not cleaning the floors completely could be a fall hazard, infection control, and could attract pests.
Record review of the facility policy Floors, dated as revised December 2009, revealed the following [in part]:
Policy Statement: Floors shall be maintained in a clean, safe, and sanitary manner.
Policy Interpretation and Implementation: 1. All floors shall be mopped/cleaned/vacuumed daily in
accordance with our established procedures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675985
If continuation sheet
Page 7 of 7
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Back to topCitations
4 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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the September 25, 2024 survey of Focused Care at Midland?
This was a inspection survey of Focused Care at Midland on September 25, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Focused Care at Midland on September 25, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.