Health inspection·August 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were treated respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #2) of five residents reviewed for dignity. The facility failed to ensure Resident #2 was not referred to as a feeder. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth . Findings include: A record review of Resident #2's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included contracted left hand, lack of coordination, muscle weakness, dysphagia (difficulty swallowing) and dementia (loss of memory/thinking). A record review of Resident #2's admission MDS assessment, dated 6/24/24, reflected a BIMS score of 00, which indicated severely impaired cognition. This assessment reflected Resident #2 required total dependance and a one-person physical assist with eating. During an observation and interview on 8/8/24 at 12:38 p.m., Resident #2 was observed lying in bed with a meal tray by her side. CNA A said, she's a feeder and stated she had three other feeders on the hall to feed. She said she was new to the job and did not remember if she was trained on rights and dignity towards residents. During an interview on 8/8/24 at 3:55 PM, the DON said CNA A should not have used the word feeder to refer to residents who needed help eating. The DON said the language was not appropriate and could affect a resident's dignity in a negative manner. The DON stated she thought staff were trained on resident rights and dignity via computer-based trainings. The DON stated staff were monitored for resident rights and dignity through interviews and rounding by management staff. During an interview on 8/8/24 at 4:00 PM, the Administrator said residents should be referred to as the Red Napkin Program assisted dining residents. The Administrator said staff were trained on resident rights and dignity via computer-based trainings. The Administrator said the DON and other nurses monitored staff for resident rights and dignity when they made rounds. She said residents referred Page 1 of 10 676050 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0550 to as feeders was not dignified and did not show respect. Level of Harm - Minimal harm or potential for actual harm A record review of the facility's policy titled Resident Rights, dated December 2016, reflected the following: Policy Statement Residents Affected - Few Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity 676050 Page 2 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 received supervision during her meals in accordance with her care plan. This failure could place residents at risk of not having their needs met and decreased nutritional intake. The findings include: Record review of Resident #1's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently on 3/3/23. Her diagnoses included hemiplegia and hemiparesis affecting right dominant side (weakness/paralysis), muscle weakness, lack of coordination, vascular dementia (brain damage from impaired blood floor), muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and gastro-esophageal reflux disease (condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review of Resident #1's quarterly MDS assessment, dated 6/13/24, reflected her had moderately impaired cognition as indicated by a BIMS score of 11. Resident #1 required - (GG section) Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs . Eating - (how resident eats and drinks .Self-Performance - Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Support - One person physical assist. Resident #1's active diagnoses included stroke, Neurological: Cerebrovascular Accident/Transient Ischemic Attack, Stroke, Non-Alzheimer's dementia (Lewy body dementia [a common type of dementia that affects memory, movement, thinking, mood, and behavior.])Hemiplegia or Hemiparesis (weakness/paralysis). Record review of Resident #1's care plan, dated 8/8/2024, reflected the following in part: Focus: [Resident #1] have an ADL self-care performance deficit r/t disease processes/decline in health. Date initiated and revised 10/22/20. Goal: [Resident #1] risk for decline with ADL's will be minimized QD and ongoing thru the next review date. Date initiated 10/22/20, Revised on: 5/22/2024, Target Date: 8/20/24. Intervention: Eating: The resident requires supervision of 1 staff to eat initiated and revised 10/22/20. Record review of Resident #1's Nutritional Risk Assessment, dated 3/4/2024, (most recent) reflected the following in part: 676050 Page 3 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Eating: self-performance - Supervision .Nutritional assessment 1. inadequate food intake r/t mechanical problem with hand AEB resident report of pain/ trouble opening and closing left hand with food intake. Goal: No weight loss >5% 30 days. Resident to be able to consume foods adequate using her left-hand 2 .Additional Information - She reports she has a lot of pain in her left hand and that she has noticed greater difficulty when opening and closing it to self-feed . She is able to use her left hand to self feed. Still struggles with hand/arm control. Right side doesn't move Record review of the facility POC report for Resident #1, dated 8/8/24, reflected the following in part: POC [Key] 1 - Eating: Self performance - 0-Independent - no help or staff oversight at any time. 1-Supervision - oversight, encouragement, or cueing. 2 - Limited Assistance - Resident highly involved in activity. Staff provided guided maneuvering of limbs or other non-weight-bearing assistance . 2- Eating: Support Provided - (How resident eats and drinks, regardless of skill . 1-Setup help only. 2One-person physical assist . 8/1/24 - 8/8/24 - Resident #1 did not received the level of assistance required based on her Care Plan and MDS (The Resident requires Supervision of 1 staff to eat) 21 out of 23 meals documented. 8/1/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/2//24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/3/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/4/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/Setup help only). 8/5/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Supervision/Setup help only). 8/6/24: Breakfast (Limited Assistance/One person physical assist) Lunch (Limited Assistance/One person physical assist) Dinner (Supervision/Setup help only). 8/7/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Supervision/Setup help only). 8/8/24: Breakfast (Supervision/Setup help only), Lunch (Observed) - (Independent/Setup help only). Record review of Resident #1's weights reflected the following: 7/2/24 - 220.6 lbs. 676050 Page 4 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0656 7/3/24 - 218.4 lbs. Level of Harm - Minimal harm or potential for actual harm 7/4/24 - 217.2 lbs. 7/5/24 - 218.4 lbs. Residents Affected - Few 7/18/24 - 216.4 lbs. 7/22/24 - 212.8 lbs. 3.54% weight loss between 7/2/24 - 7/22/24 In an observation and interview on 8/8/24 at 12:36 PM - 12:56 PM, revealed Resident #1 was delivered her lunch tray (meat, vegetables, mashed potatoes and two beverages) at 12:36 PM and the staff left the room and continued delivering lunch trays. Staff did not enter the room to assist Resident #1 eat her food. She ate with her left hand. When Resident #1 brought each bite of food to her mouth it would fall off the fork because her hand was unsteady and shook while she ate. She said her hand was weak and it was difficult. Resident #1 attempted to drink her juice. She picked up the cup and attempted to drink the beverage as her hand began to shake. Resident #1 attempted to bring the cup to her lips but she wasted the beverage due to her hand shaking. She said she did not receive assistance or asked if she needed assistance while she ate. She continued to try and eat her food. This State Surveyor requested Resident #1 push her call light. CNA A responded to the call light. Resident #1 said she was tired of trying to eat because her hand was shaking and said to CNA A it was hard to eat because she kept wasting her food. Resident #1 said if she had help she would have finished her food. Resident #1 ate 25% of her food. Staff did not supervise Resident #1 when she ate her food. During an interview on 8/8/24 at 12:58 PM, CNA A said, Resident #1 did not require assistance or supervision while she ate. She said Resident #1 required set up with her meal tray. She said Resident #1 was able to eat independently. She said the nurses informed her about the amount of assistance Resident #1 needed. CNA A said Resident #1 may have eaten slow, but she was able to eat without assistance or supervision. She said she could check the POC. She said she was feeding another resident when Resident #1 pushed her call light. She said she was not aware of Resident #1's care plan interventions. In an interview on 8/8/24 at 1:03 PM, the DON said if Resident #1 needed help, she should have been assisted with her meal. She said Resident #1 was able to feed herself. She said the care plan intervention (the resident requires supervision of 1 staff to eat ate initiated and revised) meant the facility staff should have Resident #1 by going in and out of her room while she ate her food. She said it did not mean a staff did not need to physically assist Resident #1. The DON said she was not able to answer questions on the coding for the MDS Nurse and the Reg. The MDS RN would answer questions related to assistance level indicated in Resident #1's MDS. She said Resident #1's food intake could be diminished if she was not assisted to eat. In an interview on 8/8/24 at 1:15 PM with the Regional MDS RN said Resident #1 needed supervision for eating. She said Resident #1 should have been provided set up and periodically supervised through out the time she ate. She said if staff did not go in the room and supervise Resident #1 while she ate then Resident #1, did not receive the correct level of assistance. She said the facility should re-educate staff on what was expected related to care plans and how interventions should be carried out. 676050 Page 5 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 8/8/24 at 4:00 PM with the ADMIN and the DON, the ADMIN said she expected staff to support and assist Resident #1 based on the care plan intervention ( The Resident requires Supervision of 1 staff to eat). The ADMIN said staff should have been available in the room to meet Resident #1's needs. The DON said the care plan may not have been updated because she thought the resident did not need physical assistance. The ADMIN said the care plan should be followed until it was updated if needed. The ADMIN said the resident was at risk for not being able to eat all of her food. Record review of the facility policy on Comprehensive Care Plan (effective date 1/20/21 and revised 4/25/21) reflected the following in part: .Policy - Every resident will have an individualized interdisciplinary plan of care in place .6. The resident .a. The initial goals of the resident include the GG section . c. Any services and treatment to be administered by the community and personnel acting on behalf of the community 676050 Page 6 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good nutrition for 1 of 6 residents reviewed for ADLs (Residents #1.) Residents Affected - Few The facility failed to ensure Resident #1 received supervision and assistance during her meals. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor nutrition. The findings include: Record review of Resident #1's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently on 3/3/23. Her diagnoses included hemiplegia and hemiparesis affecting right dominant side (weakness/paralysis), muscle weakness, lack of coordination, vascular dementia (brain damage from impaired blood floor), muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and gastro-esophageal reflux disease (condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review of Resident #1's quarterly MDS assessment, dated 6/13/24, reflected her had moderately impaired cognition as indicated by a BIMS score of 11. Resident #1 required - (GG section) Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs . Eating - (how resident eats and drinks .Self-Performance - Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Support - One person physical assist. Resident #1's active diagnoses included stroke, Neurological: Cerebrovascular Accident/Transient Ischemic Attack, Stroke, Non-Alzheimer's dementia (Lewy body dementia [a common type of dementia that affects memory, movement, thinking, mood, and behavior.])Hemiplegia or Hemiparesis (weakness/paralysis). Record review of Resident #1's care plan, dated 8/8/2024, reflected the following in part: Focus: [Resident #1] have an ADL self-care performance deficit r/t disease processes/decline in health. Date initiated and revised 10/22/20. Goal: [Resident #1] risk for decline with ADL's will be minimized QD and ongoing thru the next review date. Date initiated 10/22/20, Revised on: 5/22/2024, Target Date: 8/20/24. Intervention: Eating: The resident requires supervision of 1 staff to eat initiated and revised 10/22/20. Record review of Resident #1's Nutritional Risk Assessment, dated 3/4/2024, (most recent) reflected the following in part: .Eating: self-performance - Supervision .Nutritional assessment 1. inadequate food intake r/t mechanical problem with hand AEB resident report of pain/ trouble opening and closing left hand with food intake. Goal: No weight loss >5% 30 days. Resident to be able to consume foods adequate using her left-hand 2 .Additional Information - She reports she has a lot of pain in her left hand and that 676050 Page 7 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she has noticed greater difficulty when opening and closing it to self-feed . She is able to use her left hand to self feed. Still struggles with hand/arm control. Right side doesn't move Record review of the facility POC report for Resident #1, dated 8/8/24, reflected the following in part: POC [Key] 1 - Eating: Self performance - 0-Independent - no help or staff oversight at any time. 1-Supervision - oversight, encouragement, or cueing. 2 - Limited Assistance - Resident highly involved in activity. Staff provided guided maneuvering of limbs or other non-weight-bearing assistance . 2- Eating: Support Provided - (How resident eats and drinks, regardless of skill . 1-Setup help only. 2One-person physical assist . 8/1/24 - 8/8/24 - Resident #1 did not received the level of assistance required based on her Care Plan and MDS (The Resident requires Supervision of 1 staff to eat) 21 out of 23 meals documented. 8/1/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/2//24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/3/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/4/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/Setup help only). 8/5/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Supervision/Setup help only). 8/6/24: Breakfast (Limited Assistance/One person physical assist) Lunch (Limited Assistance/One person physical assist) Dinner (Supervision/Setup help only). 8/7/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Supervision/Setup help only). 8/8/24: Breakfast (Supervision/Setup help only), Lunch (Observed) - (Independent/Setup help only). Record review of Resident #1's weights reflected the following: 7/2/24 - 220.6 lbs. 7/3/24 - 218.4 lbs. 7/4/24 - 217.2 lbs. 676050 Page 8 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0677 7/5/24 - 218.4 lbs. Level of Harm - Minimal harm or potential for actual harm 7/18/24 - 216.4 lbs. 7/22/24 - 212.8 lbs. Residents Affected - Few 3.54% weight loss between 7/2/24 - 7/22/24 In an observation and interview on 8/8/24 at 12:36 PM - 12:56 PM, revealed Resident #1 was delivered her lunch tray (meat, vegetables, mashed potatoes and two beverages) at 12:36 PM and the staff left the room and continued delivering lunch trays. Staff did not enter the room to assist Resident #1 eat her food. She ate with her left hand. When Resident #1 brought each bite of food to her mouth it would fall off the fork because her hand was unsteady and shook while she ate. She said her hand was weak and it was difficult. Resident #1 attempted to drink her juice. She picked up the cup and attempted to drink the beverage as her hand began to shake. Resident #1 attempted to bring the cup to her lips but she wasted the beverage due to her hand shaking. She said she did not receive assistance or asked if she needed assistance while she ate. She continued to try and eat her food. This State Surveyor requested Resident #1 push her call light. CNA A responded to the call light. Resident #1 said she was tired of trying to eat because her hand was shaking and said to CNA A it was hard to eat because she kept wasting her food. Resident #1 said if she had help she would have finished her food. Resident #1 ate 25% of her food. Staff did not supervise Resident #1 when she ate her food. During an interview on 8/8/24 at 12:58 PM, CNA A said, Resident #1 did not require assistance or supervision while she ate. She said Resident #1 required set up with her meal tray. She said Resident #1 was able to eat independently. She said the nurses informed her about the amount of assistance Resident #1 needed. CNA A said Resident #1 may have eaten slow, but she was able to eat without assistance or supervision. She said she could check the POC. She said she was feeding another resident when Resident #1 pushed her call light. She said she was not aware of Resident #1's care plan interventions. In an interview on 8/8/24 at 1:03 PM, the DON said if Resident #1 needed help, she should have been assisted with her meal. She said Resident #1 was able to feed herself. She said the care plan intervention (the resident requires supervision of 1 staff to eat ate initiated and revised) meant the facility staff should have Resident #1 by going in and out of her room while she ate her food. She said it did not mean a staff did not need to physically assist Resident #1. The DON said she was not able to answer questions on the coding for the MDS Nurse and the Reg. The MDS RN would answer questions related to assistance level indicated in Resident #1's MDS. She said Resident #1's food intake could be diminished if she was not assisted to eat. In an interview on 8/8/24 at 1:15 PM with the Regional MDS RN said Resident #1 needed supervision for eating. She said Resident #1 should have been provided set up and periodically supervised throughout the time she ate. She said if staff did not go in the room and supervise Resident #1 while she ate then Resident #1, did not receive the correct level of assistance. She said the facility should re-educate staff on what was expected related to care plans and how interventions should be carried out. In an interview on 8/8/24 at 4:00 PM with the ADMIN and the DON, the ADMIN said she expected staff to support and assist Resident #1 based on the care plan intervention (The Resident requires Supervision of 1 staff to eat). The ADMIN said staff should have been available in the room to meet 676050 Page 9 of 10 676050 08/08/2024 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's needs. The DON said the care plan may not have been updated because she thought the resident did not need physical assistance. The ADMIN said the care plan should be followed until it was updated if needed. The ADMIN said the resident was at risk for not being able to eat all of her food. Record review of the facility policy on Comprehensive Care Plan (effective date 1/20/21 and revised 4/25/21) reflected the following in part: .Policy - Every resident will have an individualized interdisciplinary plan of care in place .6. The resident .a. The initial goals of the resident include the GG section . c. Any services and treatment to be administered by the community and personnel acting on behalf of the community 676050 Page 10 of 10