Focused Care at Fort Stockton

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 3 (Resident #2) residents reviewed for accommodation of needs. The facility failed to ensure Resident #2 had their call light within reach. This failure could place residents at risk for not having their needs or preferences met.

Inspectors wroteBased 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 dietary services. The facility failed on 3.24.26 to seal and date food items stored in refrigerator. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #44) of three residents reviewed for PASRR Level 1 screenings. The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #44. The PASRR Level 1 Screening dated 12/17/25 did not indicate a diagnosis of mental illness, although the diagnosis post-traumatic stress was present upon Resident #44's admission on [DATE]. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 10 residents (Residents #44) reviewed for care plans. The facility did not develop Resident #44's care plan related to diagnosis of Post-Traumatic Stress Disorder. These failures could place residents at risk for unmet care needs and decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #54) of 11 residents observed for oxygen management. Resident #54 were on oxygen and did not have NO SMOKING sign posted outside of the bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Resident #54Record review of Resident #54's admission Record dated 3.26.26 revealed an admission on 3.18.25 with a diagnosis of chronic pulmonary edema (a long-term condition where fluid accumulates in the lungs leading to persistent breathing difficulties and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure in accordance with professional standards of practice, the medical records on each resident were accurately and completely documented for 1 of 13 residents (Resident #58) reviewed for accurate medical records. The facility failed to ensure correct and complete documentation for Resident #58 who was placed in the secure unit on 5.19.25. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Record review of Resident #58's admission Record, dated 3.26.26, revealed a [AGE] year-old male, admitted 5.9.25, with a diagnosis of unspecified dementia (used when a patient shows clear signs of cognitive decline or impairment, but a specific cause cannot be determined). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection to include hand washing and enhanced precautions for 3 residents (Residents #1, #2, and #3) of 7 reviewed for infection control. The facility failed to place an Enhanced Barrier Precautions sign outside of Residents #1, #2, and #3's door on 3.24.26. This failure could place residents at risk for cross-contamination and the spread of infection. Record review of Resident #1's face sheet, dated 3.26.26, revealed a [AGE] year-old female, admitted 2.4.25, with a diagnosis of end stage renal disease, type 2 diabetes, and hypertension. Record review of Resident #1's Comprehensive MDS, dated 2.26.26, revealed a BIMS score of 5, indicating severe cognitive deficiency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse or neglect, for 1 of 8 residents (Residents #46) and 5 of 5 residents in the surveyor's confidential resident group meeting reviewed for abuse and neglect. The facility failed to ensure staff did not talk ugly to residents in the resident council meeting or make residents feel bullied (Resident #46). The facility failed to ensure staff did not talk ugly to residents, did not shun the resident when the staff thought resident made a complaint against the the staff, or played favorites with the residents This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observations, interview, and record review, the failed to implement their written abuse prevention policy and investigate allegations for 2 of 11 Residents (Residents #23 and #46) of eight residents reviewed for resident abuse and 5 of 5 residents in the confidential group interview. 1. The facility failed to ensure the staff did not retaliate against family members of Resident #23 for allegedly making a report of abuse or neglect against a staff member . As a result, the family member was afraid to visit Resident #23. 2. The facility failed to ensure Resident #46 did not feel bullied by staff 3. The facility failed to have mechanism in place to ensure families and residents felt safe to report allegations of abuse, neglect, or misappropriation. 4. The facility failed to have the number for the HHS Hotline Posted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 4 rooms (Rooms #101, #102, #104 and #113) out of sixteen resident rooms on 100 hall reviewed for accident hazards, in that; The facility failed to ensure that the hot water temperatures in the sinks for 5 resident rooms did not exceed the maximum of 110 degrees Fahrenheit. This failure could place residents at risk for injuries related to hot water temperatures.

Inspectors wroteBased on interview and record review , the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 (Resident #2 and Resident #5) residents reviewed for care, in that: The facility failed to ensure CNA B did not performed blood draws on Resident's #2 and #5 before becomingwithout being a certified phlebotomist and without the assistance of a nurse. This failure could affect residents by placing them at an increased and unnecessary risk of exposure to infections. Findings Included: Record review of Resident #2's admission record dated 11/13/2024 indicated he was admitted to facility on 10/18/2023 with diagnoses of reduced mobility and muscle weakness. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 (Residents #212) reviewed for indwelling catheters. The facility failed to ensure Resident #212 indwelling catheter was emptied when full to prevent it from exploding. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 4 (Resident # 2, 7, 8, &9) rooms reviewed for environment. The facility window blinds in Resident #2, 7, 8, &9's rooms were inoperable and damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well- kept environment.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 20 residents (Resident # 38, Resident #61) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #38 prior to administering Sertraline, an antidepressant used to treat depression. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 2 medication carts reviewed for pharmacy services, in that: . The medication cart used for hall 100 had an insulin pen that had expired as indicated by the manufacturers recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. These failures could place the facility at risk of drug diversion and access to medications. Findings Include: During an observation on 10/04/23 at 09:18 AM the DON's office door was observed to be unlocked, open, unsupervised and no staff present. During an observation and interview on 10/04/23 at 10:44 AM the discontinued controlled medication storage was inspected with the DON present. [...]