The March 25 attack was the third violent incident involving Resident #3 in four months. Federal inspectors found the facility failed to protect other residents from repeated assaults and failed to report the incidents to state authorities within the required two-hour window.
Inspectors declared an immediate jeopardy situation on April 16, meaning residents faced serious injury or harm. The facility removed the immediate jeopardy the next day by discharging Resident #3 and implementing emergency monitoring procedures.
The pattern began November 30, when Resident #3 and Resident #4 fought in the smoking area. Both residents fell to the ground, with staff describing "few slaps back and forth" before they were separated. Resident #3 sustained scratches to his left arm.
Three months later, on February 15, Resident #3 blocked a doorway when Resident #5 tried to reach the smoking area. After Resident #5 asked him to move, Resident #3 "cussed him out" and appeared ready to fight. Resident #5 struck him with a walker, and both fell to the dining room floor. Resident #3 suffered a small abrasion to his back.
The most serious incident occurred March 25 during breakfast. A nursing assistant was feeding Resident #6, who has severe cognitive impairment and requires substantial assistance with transfers, when Resident #3 "decided to kick him multiple times."
Resident #3 later told the social worker he had kicked Resident #6 "for no real reason" and knew it was wrong. In a separate interview with inspectors, he said he was "jealous the staff were feeding Resident #6 and not him."
The facility sent Resident #3 to a behavioral hospital after the breakfast attack but readmitted him April 2.
Staff described Resident #3 as someone who "liked to stir the pot and instigate arguments with residents and staff." His care plan documented verbal aggression, describing him as "loud and obnoxious" who would "instigate arguments."
The Director of Nursing told inspectors Resident #3 had been in multiple nursing homes before arriving at Focused Care. Adult Protective Services had been involved when he lived at home with his mother because he "had acted out and called the police many times."
Resident #3 acknowledged his behavior during interviews. "I am a sweet guy but when you make me mad, I turns into the devil," he told inspectors. "I did not have control over my actions when I gets mad."
He said he had been kicked out of another nursing facility "for trying to bite the medication aide's finger."
The facility's own records show a pattern of escalating problems. Progress notes document Resident #3 making "flirtatious comments towards staff and some female residents" and "touching female staff inappropriately." Staff educated him in February that the facility "cannot tolerate him touching the female staff on the bottoms or anywhere else."
One resident, who calls bingo when the activity director is unavailable, said Resident #3 "yells out at her when she calls bingo like a bully would." She said he had asked her and other female residents and employees for sex.
"I was not afraid of him physically, but I was afraid of what he brought out in me and was afraid I would hit him," she told inspectors.
Another resident said Resident #3 had "problems with a lot of residents because he was always in other peoples business and cussing other residents."
Despite the documented pattern of aggressive behavior, the facility failed to prevent further incidents. After the November fight, staff simply told both residents to stay away from each other and prohibited them from smoking together that evening. After the February incident, they separated the residents but allowed Resident #3 to remain in contact with other vulnerable residents.
The facility also failed to report the incidents to the Texas Health and Human Services Commission within the required two hours. Their own policy states that "all events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours."
The social worker sent six referrals seeking alternative placement for Resident #3 between April 1 and April 15. All were denied.
When inspectors arrived, they found the facility had moved Resident #3 back to the same hallway as some of his previous victims. Resident #7 said she "felt so much better when he resided on a different hallway" but was distressed when he returned April 14.
The Administrator told inspectors she knew Resident #3 had behavioral problems before admission but accepted him anyway because "she felt like they could help" him. She said her expectation was "to do their best to prevent abuse and if something did happen they reported and took action."
But facility records show inconsistent follow-through. While Resident #3 was referred for counseling services in November, he refused treatment. He didn't receive counseling until February, and only after staff documented inappropriate touching of female employees.
The immediate jeopardy was removed April 17 after the facility discharged Resident #3 and implemented emergency procedures. All staff received training on abuse prevention and de-escalation techniques. The facility conducted safety surveys with 66 residents, with three expressing concerns about Resident #3's behavior.
One resident told surveyors a nursing assistant had been "rough during her bed bath," but after further investigation, managers determined the resident required two-person assistance and updated her care plan accordingly.
The facility implemented one-to-one monitoring for Resident #3 on April 16 at 7:20 p.m. and maintained continuous observation until his discharge the following morning at 7:52 a.m.
Resident #3's medical conditions included bipolar disorder, impulse control disorder, Parkinson's disease, and Wilson's disease, which causes copper to build up in organs including the brain. Despite these diagnoses affecting impulse control and behavior, his cognitive assessment showed no impairment.
The three residents he attacked had varying levels of vulnerability. Resident #4 has vascular dementia and left-side paralysis but walks independently. Resident #5 has brain damage from toxic exposure and diabetes. Resident #6, the breakfast victim, has severe cognitive impairment from a stroke and cannot speak due to aphasia.
Federal inspectors noted that while the immediate jeopardy was removed, the facility remained out of compliance due to the need to evaluate whether their new systems would effectively prevent future incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care of Center from 2025-04-22 including all violations, facility responses, and corrective action plans.
