Focused Care at Odessa

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for physical environment. The facility failed to maintain the clothes washers in working condition. This failure placed residents who relied on the facility for laundry services improperly cleaned clothes and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring and administering of all medications to meet the needs of 1 of 5 (Resident #1) residents reviewed for pharmacy services in that: MA A failed to ensure Resident #1 took her medications at the time of administration and left them on the bed side table. This failure could place residents at risk for medication overdose, medication under-dose, drug diversion, and not receiving therapeutic doses of prescribed medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 set of window blinds in room [ROOM NUMBER] and 1 of 1 resident smoking areas. 1. The facility failed to ensure the blinds were not broken.2. The facility failed to ensure adequate cleaning in the designated smoking area. These failures placed the staff, residents, and visitors at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety.1. The facility failed to discard cabbage in a box dated 12/8/2025, containing brown and rotted leaves, in the reach-in cooler.2. The facility failed to ensure an opened bag of grits in the dry storage room was properly sealed and dated. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #2) of 3 residents reviewed for informed consents. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #2 prior to administering an increased dose of Seroquel, a psychotropic medication (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #13) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #13's window blinds while providing incontinent care and a change of clothes for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Agency for 1 of 4 residents (Resident #20) reviewed for abuse in that: The facility did not report to the State Survey Agency that Resident #20 reported an allegation of abuse to the administration within 2 hours of the incident. This deficient practice could place residents at risk for not having all allegations of abuse and neglect reported to the State Survey Agency in a timely manner. Findings Include: Record review of Resident #20's admission record dated 01/07/2026 revealed he was admitted to the facility on [DATE] with diagnosis of Parkinson's disease, schizophrenia, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #20's MDS assessment dated [DATE] revealed in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to have nursing staff with appropriate competencies to provide nursing and related services to assure resident safety and attain/maintain the highest practicable well-being of each resident for 1 of 1 nursing staff reviewed for nursing services. The facility did not provide evidence that LVN E was competent and received training on resident care plans and implementing care according to care plans. This failure could place the residents at risk for not receiving required care, complications, injury, hospitalization, and decline in conditionFindings included:During an interview on 1/7/2026 at 3:20PM LVN E stated she did not know how to read care plans. LVN E stated she had not received training in reading or implementing care plans. LVN E stated she had worked at the facility for 7 years. [...]

Inspectors wroteBased 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.

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 6 (Residents #6, #7, #8, #9, #10, and #11) of 6 residents observed for oxygen management. The facility failed to ensure that Residents on oxygen (#6, #7, #8, #9, #10, and #11) had oxygen signs posted outside their bedrooms (Rooms 4, 14, 15, 20, 26, and 33). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents environment remained as free of accidents and hazards as possible, and each resident received adequate supervision to prevent accidents for 1 (Resident #7) of 5 residents reviewed for transfers. The facility failed to ensure Resident #7 had floor mat at bedside when in bed to prevent falls with injury that occurred on 05/12/2025. This failure could place residents at risk for falls or injuries.

Inspectors wroteBased on interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #4) of 3 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased 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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #6) residents reviewed for infection control. The facility failed to ensure Resident #6 had a contact isolation on her door alerting visitors she was in isolation related to shingles. This failure could place residents at risk of cross contamination which could result infections or illness.

Inspectors wroteBased on interview and record review the facility failed to report an alleged violation of injury of unknown origin immediately to the administrator of the facility and to other officials (including to state survey agency) in accordance with State law and according to their policy for 1 (Resident # 3 ) of 2 residents reviewed for allegations of abuse. The facility failed to report Resident #3 's allegation of abuse related to LNV C's alleged withholding of medication to State Office. This failure could place all residents at risk for abuse and/or neglect by not immediately reporting allegations of abuse to the proper authorities at the facility. Findings Include: Record review of Resident #3's face sheet dated 5/14/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of generalized anxiety, schizophrenia, and bipolar disorder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 5 (Resident #4) residents reviewed for activities. The facility failed to provide regular, individualized activities to Resident #4. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. This failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #7) of 6 residents reviewed for accuracy of records. The facility failed to ensure LVN C documented Resident #7's return from the hospital. This failure could have placed residents at risk for inaccurate medical records.

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 the facility's only kitchen. The facility failed to ensure: Food that was beginning to rot (discoloration and had rotten smell) was discarded. Staff knew how to check the sanitizer level in the dishwasher. Staff knew how to wash their hands. Food was dated per the facility's policy. Food was not stored on the floor. The dry storage and refrigerator were clear of debris and food under the shelves. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 13 of 13 residents in the confidential group interview. Staff used cell phones in residents' presence causing residents to feel disrespected and ignored. Staff had residents sit at assigned seating in the dining room. Staff labeled resident's clothing in large print over their clothing. These failures could result in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #17, #18 and #51) reviewed for transfers and supervision in that: Nursing staff and Resident #17's doctor were not aware Resident #17 had his right leg secured to his footrest with a gait belt. CNA A transferred Resident #18 from his bed to his wheelchair by taking him from his under arms. CNA G and CNA H transferred Resident #51 from his wheelchair to his bed taking him from under his arms and by the back of his pants. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.

Inspectors wroteBased 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 3 (Resident #18, Resident #41 and Resident #20) of 6 residents reviewed for incontinent care in that: CNA A failed to change her gloves after they became contaminated and wash or sanitize her hands in between glove change while assisting Resident #18 with incontinent care. CNA B failed to change their gloves after they became contaminated while assisting Resident #41 and Resident #20 with incontinent care. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #17) reviewed for care plans in that: The facility failed to ensure there was a care plan in place for Resident #17's ankle enabler. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #20, Resident #41) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen was ordered for both Resident #20 and Resident #41. This failure could place residents at risk of not receiving appropriate respiratory care.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure 1 of 6 residents (Resident #1) received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure Resident #1's four wound dressings were dated and initialed per facility policy. This deficient practice could affect residents who received pressure ulcer preventative treatments and place them at risk for skin breakdown, infection, pain, and a decline in health.

Inspectors wroteResident #4 FTag Initiation Resident #41 FTag Initiation Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 12 residents (Residents #4, #8, #11, #57) reviewed for care plans in that: 1. The facility failed to ensure Resident #4 had a care plan in place to address her cognitive status or pain management. 2. The facility failed to ensure Resident #8 had a care plan in place to address her delirium or the decline in her behavioral status. 3. The facility failed to ensure Resident #11 had a care plan in place to address his ADL status. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 4 of 4 medication carts at the nurses station reviewed for medication storage in that: 1. The facility failed to ensure LVA A secured the medication carts when they were left unattended. 2. The facility failed to ensure LVN B secured the treatment cart when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #11) of 12 residents reviewed for quality of care. The facility failed to document or communicate that the resident was removing his tube feedings during feeding times. This resulted in Resident #11 not receiving his full recommendation of prescribed formula. This failure placed residents at risk of decline and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 2 of 4 residents (Resident #16 and #61) reviewed for infection control. 1. CNA C failed to perform hand hygiene appropriately while providing incontinent care for Resident #16. 2. CNA D failed to perform hand hygiene appropriately while providing incontinent care for Resident #61. These failures could place residents at risk for transmission of diseases and organisms.