Health inspection·January 26, 2024

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent decrease in range of motion for 1 of 12 residents (Resident #49) reviewed range of motion. -The facility failed to ensure Resident #49, with contractures to both hands, was wearing a hand splint device on both hands as care planned and ordered by the physician. - This failure could place resident at risk for further contractures of the hands and fingers, pain, and a decrease in quality of life. Findings: Record review of Resident #49's face sheet dated 11/01/2023 revealed a [AGE] year-old female admitted to the facility originally on 10/07/2020 and again on 05/09/2023 with the following diagnoses that included: subarachnoid hemorrhage (blood vessel that bursts in the brain) , sickle cell disorder with cerebral vascular involvement, cerebral infarction (disrupted blood flow to the brain), narcolepsy ( sleep disorder causing daytime drowsiness) , contracture of hand (fixed tightening of a body part that prevents movement), aphasia (language disorder that effects a person's ability to communicate), pain in unspecified fingers, cognitive deficit, dysphagia (difficulty swallowing), diabetes mellitus, and gastrostomy (opening into the stomach surgically for the introduction of food/nutrition). Record review of Resident #49's quarterly MDS assessment dated [DATE] revealed that the resident's BIMS score was 3 indicating that the resident's cognition was severely impaired. Further review revealed that resident upper and lower extremities were impaired. Record review of Resident #49's Care Plan dated 07/14/2022 revealed that resident was being care planned for musculoskeletal status r/t contracture of bilateral hands with interventions included the following: -Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. -Provide and apply bilateral UE Splints Record review of Resident #49's Physician Orders revealed the following orders: Page 1 of 8 676116 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0688 -Dated 03/08/2021 for bilateral splints UE to be worn at least 5 days a week or as tolerated. Level of Harm - Minimal harm or potential for actual harm -Dated 06/06/2023 Tylenol give 650mg via peg tube (surgically inserted feeding tube) q 12 hours for joint pain contractures, do not exceed 3gm q 24 hr. Residents Affected - Some Record review of Resident #49's MAR for the month of January 2024 revealed that the facility was administering the resident's Tylenol as ordered by the physician. Record review of Resident #49's Occupational Therapy Discharge summary dated [DATE] revealed in part: .Patient will safely wear a hand roll on and finger separators on right fingers, right hand, left hand and left fingers for up to 8 hours . Observation on 01/23/24 at 10:05AM revealed Resident #49 was resting in bed with a touchpad call light within reach. Resident #49 had side rails to upper bed. Resident was receiving continuous gastrostomy feedings Jevity at 1.5 at 45ml/hr hung on 1/23/24 at 5:00AM. Further observation was made of resident with both hands with contractures and no splint device to prevent further contractures. Observation on 01/23/24 at 3:00PM revealed Resident #49's hands with no device in her hands for contractures. Resident was resting quietly and did not appear to be in discomfort. Observation on 01/24/24 at 8:20AM, 9:45AM, 10:25AM, 12:20PM, and 5:00PM of Resident #49 revealed she was resting quietly in bed with head of bed elevated. Resident with no devices in hands. Observation 01/25/24 at 9:10AM and 12:00PM of Resident #49 revealed with no hand splints being worn. Interview on 01/25/2024 at 9:10AM, LVN Z said she was Resident #49's nurse. LVN Z said she had not worked at the facility in a long time. LVN Z said she was not sure if resident had an order for any type of splint device for her hand and finger contractures. LVN Z said she saw that resident had contractures to both of her hands and fingers. LVN Z said it was important to place something in Resident #49's hands to prevent resident hands from becoming more contracted. Interview on 01/25/24 at 9:28AM, the Director of Rehab said the last time Resident #49 was on OT services was 11/01/2023. The Director of Rehab said she started working at the facility in December of 2023. The Director of Rehab said she was not sure if Resident #49 had orders for hand contractures. The Director of Rehab said residents with hand contractures wore a hand splint device to prevent pain and neuromuscular dysfunction. The Director of Rehab said if a resident with contractures was not receiving treatment for the contracture, they could regress. The Director of Rehab said she was in the process of assessing all residents on Rehab Therapy. The Director of Rehab said the Physical Therapy staff were all new staff. Interview on 01/25/2024 at 10:35AM, the DON said before she was hired as the facility's DON, the facility did not have a restorative program. The DON said she addressed a restorative program with the Administrator who was supposed to be checking into the matter. The DON said when the facility had a restorative program, CNA R was the restorative aide. The DON said CNA R was supposed to continue to make sure that the residents that had contractures were wearing their splints or contracture devices. The DON was asked for the facility policy on quality of care/restorative care. The DON said the 676116 Page 2 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0688 facility did not have a policy on Quality of Care, but submitted a policy on restorative services. Level of Harm - Minimal harm or potential for actual harm Interview on 01/25/2024 at 10:55AM, CNA R said she was the facility's restorative aide when the facility had the restorative program. CNA R said although the facility no longer had a restorative program, she was doing the best she could to ensure that the residents with contractures were wearing their contracture devices to help with range of motion. CNA R said she guessed she missed checking for Resident #49. Residents Affected - Some Interview on 01/25/2024 at 11:00AM, the Administrator said the NF had not had a restorative program since she had been working at the facility for the past several years. Interview on 01/25/2024 at 12:20PM, CNA O said she worked at the facility PRN on the morning and evening shift. CNA O said she was Resident #49's CNA. CNA O said she could only speak for herself and did not recall ever being in-serviced on contractures or how to care for residents who had contractures. CNA O said she just knew to clean the palms of a resident hands who had hand contractures to ensure their hands were clean. Observation on 01/25/2024 at 12:25PM of the palms of Resident #49's hands revealed they were clean with her skin intact, resident was not wearing a hand splint. Observation on 01/25/2024 at 12:45PM of Resident #49's family member revealed the family member standing at Resident #49's bedside rearranging resident linen on bed. Interview on 01/25/2024 at 12:45PM with the family member of Resident #49 revealed she was not against the facility providing some type of hand splint to the resident's hands and fingers to prevent further contractures. The family member said she was trying to get the previous PT that used to work at the facility to help her with getting splints for Resident #49's hands and fingers to help keep resident hands and fingers extended as much as possible. The family member said PT never got resident the splints for her upper extremities. The family member said she was continuing to look for some type of device for resident contractures to her hands and fingers. Record review of the facility policy on Restorative Nursing Services revised July 2017 revealed in part: .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Restorative goals and objectives are individualized and resident-centered, and are outline in the president's plan of care .Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities; developing, maintaining his/her dignity, independence and self-esteem; and participating in the development and implementing of his/her plan of care . 676116 Page 3 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that The facility failed to prevent the following. 1. A Plastic Container of Shredded Cheese dated 1/15/24. 2. A Plastic Container of Mozzarella Cheese dated 1/02/24. 3. A Plastic Container of Chili dated 1/02/24. The scoop was left in the flour bin in the storeroom. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/23/24 at 8:30 AM revealed that leftover foods were not discarded prior to the use by date. Observation of the facility's food storeroom on 01/23/24 at 8:40 AM revealed that a scoop was left in the flour bin. Interview with the Food Service Manager on 01/23/24 at 8:45 AM he stated that the leftover food stored in the refrigerator should have been used or discarded prior to use by date. He stated that he will in-service dietary staff on policy and procedure for leftover food and scoops storage. Record review of facility's policy and procedure for food storage dated 9/20/23 revealed that food products are discarded before the use by date. The facility failed to follow the policy for food storage including leftover opened containers of potentially hazardous food or leftovers are dated or used with in 7 days in the refrigerator. 676116 Page 4 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services in that Residents Affected - Few -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-23-24 at 9:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and food refuse and the door was wide open. In an interview on 01-23-23 at 9:20 am, with the Food Service Manager, he stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He also stated that he will in service dietary staff that the dumpster door is to be always closed for proper sanitation and residents' safety. Requested a copy of policy and procedure for Waste Disposal/Dumpster of the facility. Facility did not provide the requested copy before exit. 676116 Page 5 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 Residents (Resident #78) reviewed for administration. -The facility failed to completely and accurately document Resident #78's use of splint/braces on his care plan; These failures could place residents at risk of having incomplete and inaccurate records. Findings include: Record review of Resident #78's clinical record revealed he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include: cerebral palsy (disorder effecting movement and ability to maintain balance), depressive episodes, severe intellectual disabilities, pulmonary fibrosis (scarring of the lungs cause difficulty to breath), end stage renal disease (kidney failure), encounter for palliative care (medical care focused on pain relief and comfort), and protein-calorie malnutrition (underweight). Record review of Resident #78's quarterly review MDS (Minimum Data Set) assessment dated [DATE] revealed that his BIMS (Brief Interview for Mental Status) was not scored. The resident's cognitive skills for daily decision making was scored as 3 which indicated his cognition was severely impaired. Record review of Resident #78's Care plan dated 3/5/18 revealed: Focus area cerebral palsy affected the ability for Resident #78 to speak or ambulate and receive medication daily for increased movements. Goal: Resident #78 to be able to function at the fullest potential possible as outlined by the treatment team throughout the next review date. Interventions: Maintain good body alignment to prevent contractures. Use braces and splints as ordered. Record review of Resident #78's orders revealed no orders for braces and splints. An observation on 01/23/2024 at 09:53 AM revealed Resident #78 laying in fetal position on his left side with his arms bent to his chest, and his hands and feet were contracted. No braces or splints on resident's hands, legs or feet. Resident appeared to be asleep and nonresponsive. An observation on 01/24/2024 at 11:10 am revealed Resident #78 laying in fetal position on right side. Resident appeared to be awake but nonresponsive. Resident's arms bent to chest and hands contracted. No braces or splints observed on resident's hands. An observation on 01/25/2024 at 09:49 am revealed Resident #78 laying in fetal position on left side. Resident appeared to be awake but nonresponsive. Resident's arms bent to chest and hands 676116 Page 6 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0842 contracted. No braces or splints observed on resident's hands. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/25/24 at 12:42 pm, the Rehabilitation Director (RD) stated that she was over occupational therapy (OT) and physical therapy (PT). She stated she assigned admissions, baseline and quarterly evaluations for residents receiving part A Medicare services. She stated at the time, the evaluation would determine if a resident with contractures was capsular (highly treatable) or fixed (untreatable) and whether the resident would benefit from positioning and splints or braces. She stated if a resident required services, she would request authorized by their physician. She stated a resident with a fixed contracture would not benefit from a splint or brace, rather it would cause more damage and more than likely pain. She stated that she was not familiar with Resident #78. She stated that she was unaware of how many residents with contractures were on census. She stated that the facility does offer in facility restorative services. She stated that they outsource restorative services with a telehealth agency. Residents Affected - Some In an interview on 01/25/24 at 02:00 pm, the RD stated that she did not know the true number but believes there are a total of 11 residents with contractures. In an interview on 01/25/24 at 02:14 pm, the Certified Occupational Therapy Aid (COTA) stated she was hired in October of 2023. She stated she performed the physical joint mobility (moved resident's limbs) during telehealth evaluations as directed by the physiatrist. She stated she was not aware of how many residents had contractures. She stated she was given her assignments by the RD and was the only COTA on staff. She stated she only had 3-residents on her caseload. She stated she was not familiar with Resident #78, his contractures, and had not evaluated him. In an interview on 01/25/24 at 02:23 pm, the DON stated she started working in the facility in June 2022. She stated that MDS B took the role of MDS on 12/06/2023 and MDS A started training around thanksgiving and acquired the role in December 2023. She stated she was unaware of the total residents with contractures. She stated evaluations were scheduled by MDS A and performed quarterly by MDS A and the RD every Friday. In an interview on 01/25/24 at 03:07 pm, the MDS A stated that she had been the MDS and trained since 11/03/2023 under MDS B. She stated that the corporate registered nurse (RN) had begun providing guidance to her when MDS B was terminated 01/03/2024. She stated MDS A and therapy services had meetings every Friday to discuss assessment needs such as residents who were coming off or on therapy, who had a change in condition, or who were up for quarterly review. She stated that Resident #78 had not come up on her caseload and she had not completed his quarterly MDS or care plan since she had been hired. In an interview on 01/25/2024 at 04:46 pm, the DON stated that she had not been made aware that Resident #78's care plan reflected use braces and splints as ordered. She stated that resident had not had an order since he had been admitted for braces/splints. She stated that if he was to have had braces/splints an order should have been received and reflected on his care plan. She stated if there was not an order, braces/splints should not have been reflected on his care Plan. She stated it would have been MDS B's responsibility to complete his care plan accurately, but MDS B was terminated on 01/03/2023. She stated that the responsibility would now fall to MDS A who took over when MDS B had been terminated. 676116 Page 7 of 8 676116 01/26/2024 Focused Care at Westwood 8702 Course Drive Houston, TX 77099

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 01/26/2024 at 10:42 am, the DON stated she had spoken to Hospice Nurse (HN) who conformed Resident #78 had no previous order for braces, splints, or therapy. She stated she would update his care plan and also submit authorization and referral for a therapy evaluation. In an interview on 01/26/2024 at 12:37 pm, the NP stated that she has been over Resident #78's care since admission and resident had never had an order for any braces or splints. In an interview on 01/26/2024 at 12:43 pm, the HN stated that Resident #78 had been under his care since 03/29/2023 and had a recent (Individual Development Plan) meeting (exact date not given). He stated since providing the resident care, there had not been an order, discussion, or care plan for resident to have had splints or braces. In an interview on 01/26/24 at 12:55 pm, the Administrator stated that Resident #78 had never had an order for splints or braces. She stated that the DON and MDS B were responsible for the resident's care plan. She stated that MDS B may have opened up the wrong care plan when updating Resident #78's care plan. She stated, at some point, his care plan was initiated and/or updated by too many individuals who were unaware what the last individual had or had not done. She stated that the adverse effects of an inaccurate care plan could result in misdiagnosis and missed care for residents. She stated the MDS A was new, and the RN had been assisting with MDS and care plan suggestions and updates. She stated that the resident's care plan would be corrected. She stated the DON and herself were responsible for care plan and MDS in-services. In an interview on 01/26/2024 at 01:28 pm, the RN stated that that she was not familiar with Resident #78 diagnoses or care plan. She stated that she had been assisting MDS A since MDS B had been terminated. She stated that the all department heads were responsible for ensuring that the care plans were accurate. She stated that inaccurate care plans would result in resident care plans not being followed correctly and resident's not receiving accurate care. Requested a copy of policy and procedures related to clinical records. The facility did not provide the requested copy before exit. 676116 Page 8 of 8