Focused Care of Waxahachie

Inspectors wroteBased on interview and record review, the facility failed to protect 1 (Resident #1) of 7 residents reviewed for abuse and neglect in that:The facility failed to ensure Housekeeper A was not verbally aggressive with Resident # 1 on 05/22/2026. This failure could place residents at risk of emotional distress and psychosocial harm.

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 facility reviewed for environmental concerns. 1. The facility failed to repair a jagged lifted piece of metal with a pointed edge, which was present to the outside of the door, which opened to go out to the designated smoking area of the facility. 2. The facility failed to repair the magnet which was hanging out of the wall for the facility fire door which lead out of the dining room on the 400 hall. 3. The facility failed to repair or replace the door mechanism cover for the smoking door which lead from the sunroom resulting in exposed wiring and door mechanism at the top of the door. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed ensure the resident had a right to personal privacy and confidentiality of his or her personal and medical records for 15 of 20 residents (Residents #12, #54,#13, #10, #6, #49, #27,#47, #30, #33, #69, #20, #21, #45 and #29) reviewed for privacy and confidentiality. 1. The facility failed to ensure Residents #47, #30, #33, #69, #20, #21, #45 and #29 vital sign information was not exposed and left on top of MA F's medication cart unattended on 04/26/26. 2. The facility failed to ensure resident/responsible party education, for Out on Pass signed documents, which documented resident names and responsible party name and signatures were not exposed on the receptionist front window counter for Residents #13, #!2 and #54 on 4/26/26. 3. [...]

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 safety in the facility's kitchen reviewed for dietary services. The facility failed to ensure food was labeled and dated correctly in the refrigerator, freezer, and pantry on 04/26/26. This failure could place residents at risk of foodborne illnesses. Observation of the kitchen on 04/26/26 at 9:18 AM revealed the following:There were 2 opened packages of French fries in the freezer that did not have any dates on them. There was a container with Jello (a sweet gelatin-based dessert made from animal derived gelatin) that had a preparation date of 04/01/26 and a used by date of 04/02/26 in the refrigerator that had not been thrown away. [...]

Inspectors wroteBased on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #6) reviewed for PASARR assessments. The facility failed to ensure Resident #6 was referred to the mental health authority after receiving a new diagnosis of schizoaffective disorder. This failure could place residents at risk for a diminished quality of life and not receiving needed care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 one (Resident #1) of six residents reviewed for infection control. The facility failed to ensure staff practiced hand hygiene when entering and exiting Resident #1's room, who required enhanced barrier precautions. The failure put residents at risk for infection, hospitalization, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 1 of 8 residents (Resident #1) reviewed for safety. The facility failed to ensure Resident #1 was provided adequate supervision on 02/08/2026 when Resident #1 pushed open a facility exit door, activating both the door alarm and Resident #1's wander guard alarm, and exited the facility traveling approximately 500 ft, crossing a street, and falling (no injuries). The facility was notified by a passerby driving a car of resident's elopement. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/08/2026 and ended on 02/09/2026. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for avoidable accidents, injuries, and possible death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident #1) of six residents reviewed for infection control CNA A failed to cleanse the perineal area (vaginal area), change her gloves, wash her hands and dispose of the soiled brief in a designated container during incontinent care for Resident #1. This failure could place residents at risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 6 residents reviewed for pharmacy services, in that: 1) The facility failed to administer medications correctly on 10/3/2025 at 6:00 am.2) The facility failed to administer medications correctly on 10/3/2025 at 4:00 pm.3) The facility failed to administer medications correctly on 10/5/2025 at 8:00 am This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of eight (8) residents reviewed for accurate clinical records, in that: The facility failed to ensure assessments for Resident #1 were documented in the medical record after he was discovered with ants on him while lying in bed on 10/22/2025. This deficient practice could result in errors in care and treatment and violate resident rights.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the residents' representative of the changes in the resident's physical and mental health for one (Resident #1) of seven residents reviewed for notification of changes. The facility failed to ensure Resident #1's RP was notified when he was found with ants on him while lying in bed on 10/22/2025. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for environment. The facility failed to ensure Resident #1 was provided clean bed linens that were in good condition. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities. The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025. This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #12) of 8 residents who were reviewed for accuracy of assessments. The facility failed to ensure Resident #12's MDS assessment accurately reflected his hearing ability and use of hearing aids. This failure could place residents at risk of their needs going unmet.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 2 (Resident #16 and Resident #52) of 14 residents reviewed for PASSAR assessments. Resident #16 did not have a new PASSAR level I screening completed or a PASSAR level II screening completed although a diagnosis of mental illness was diagnosed after the admission date. Resident #52 did not have an accurate PASSAR Level 1 screening after Resident #52 was admitted with a negative PASSAR Level 1 screening but had a mental illness. These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. Findings Included: [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans. The facility failed to care plan Resident #12's use of hearing aids. This failure could place residents at risk of their needs going unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300. These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 13 residents (Residents #2, #3, #4, & #5) reviewed for resident rights in that: The facility failed to ensure Residents #2, #3, #4, & #5's call light was within reach on 12/20/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 13 residents (Residents #1, and #5) reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect an unwitnessed fall out of bed on 12/11/24 and 12/14/24. The facility failed to revise Resident #5's care plan to reflect interventions for nutritional impairment, behavior problem, and resistive to care that was initiated on 11/20/24. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, 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 and treatment alternatives or treatment options and to choose the alternative or option he prefers for one (Resident #1) of four residents reviewed for consents. The facility failed to obtain a written consent from Resident #1 before administering the following psychoactive medications: Risperdal (anti-psychotic), Paroxetine (anti-depressant) , Depakote (mood stabilizer , Nudexta (anti-depressant), Quetiapine (antipsychotic), Lorazepam (anti-anxiety). [...]

Inspectors wroteBased on interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure they had enough Depakote medication (mood stabilizer medication) on hand from 3/20/2024 to 4/10/2024 for Resident #1. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and could result in worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents (Residents #1 & #2) reviewed for resident rights in that: The facility failed to ensure Residents #1 and #2 call lights was within reach on 10/29/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 7 residents (Resident #3) reviewed for a clean and homelike environment. The facility failed to ensure Resident #3's urinal was emptied appropriately on 10/29/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to protect Resident #2's right to be free from physical, mental, and verbal abuse by Resident #1. The facility failed to protect Resident #1 from abuse by Resident #2. Residents had an established and repeated facility wide known history of disputes, both verbal and attempted physical alterations. On 10/09/2024, both residents were in the same room unattended by staff and video footage revealed Resident #1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. An IJ was identified on 10/12/24. The IJ template was provided to the facility on [DATE] at 1:45 PM. [...]

Inspectors wroteBased on interviews, observations, 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 timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #1 and Resident #2) of ten residents reviewed for care plans. The facility failed to implement a comprehensive care plan for Resident #1 and Resident #2 with attainable interventions in place addressing the repeated facility wide known history of disputes between the two Residents. An incident occurred on 10/09/24 where video footage revealed R#1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that: The facility failed to provide documentation that Resident #1 received sufficient preparation and orientation when he was discharged to a group home to ensure a safe discharge. Resident #1 was discharged from the facility on 10/11/24. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident # 1 was free from accidents. Resident # 1's leg was hit on a table by CNA A that resulted in a Tibial fracture to her right leg and was sent to the hospital for treatment services. The staff who caused the injury was moved to another hall. This failure placed residents at risk of being injured by CNA A.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for three (Residents #3, #4 and #5) out of eleven residents reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #3, #4 and #5 in order to provide care in that: Resident #3's care plan was blank, Resident #4's care plan was incomplete and had only one intervention for vaccine status, Resident #5's care plan was incomplete and had only two interventions for code status and alertness. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers which could result in injury or a decline in physical well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #2) of four residents reviewed for medication storage. The facility failed to ensure narcotics were received and then stored in a manner to prevent diversion on 03/04/2024 when a refill of Hydrocodone, 10-325 milligrams, quantity of 75, for Resident #2 was received from the pharmacy by LVN A, given to LVN B on 3/4/2024 and discovered missing on 03/06/2024. This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen, which was reviewed for dietary services. The facility failed: 1. The facility failed to properly seal, label, and date food containers in the facility's freezer. 2. The facility failed to properly defrost food at the appropriate temperature. 3. The facility failed to utilize plates that were free from chips. 4. The facility failed to monitor and maintain the appropriate sanitizer concentration the facility's only dishwashing system. 5. The facility failed to maintain clean kitchen equipment and appliances. These failures placed residents at risk of exposure to food borne pathogens.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for 1 of 1 Infection Preventionist reviewed. The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. This deficient practice could place residents at risk of cross contamination and infection.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #43) of 3 residents reviewed for accidents, hazards, and supervision. The facility failed to ensure safe smoking for Resident #43 when he had a lighter and cigarettes in his possession, outside of scheduled smoking hours unsupervised. This failure could place residents who smoke at risk of harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8.57%, based on 3 errors out of 35 opportunities, which involved 1 (Residents #46) of 3 residents reviewed for medication errors. LVN E failed to administer medication by mouth as ordered and gave medications via gastrostomy (stomach) tube. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that residents are free of significant medications error for 1 of (Resident #46) of 3 residents reviewed for medications errors. The facility failed to ensure that Resident #46's medications were given as ordered by the physician. This failure placed all resident who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 2 of 5 residents (Residents #23 and Resident #63) reviewed for influenza and pneumococcal immunizations. The facility failed to document pneumococcal immunizationstatus for Resident #23 and Resident #63. These failures could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, for 1 of 6 residents (RES #59) who were observed for access to facility services. The facility failed to ensure RES #59 had access to a functioning call light button. This failure could place residents at risk for unmet needs.