Focused Care At Westwood
Inspection Findings
F-Tag F0690
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
catheter care. Interview with the DON on 11/5/25 at 5:22 PM, she said the F/C should be hung below Resident #1's bladder and this is to prevent back flow of urine to bladder which could result in Resident #1 acquiring a UTI. The DON said she would be monitoring the CNAs randomly now. The DON said she does have monthly in -services on F/C and incontinent care. Record review of the facility's policy for Catheters and Care: Indwelling, straight, supra-pubic, and External Urinary, revised date of 4/2021 reflected: RN/LVN to insert catheter using following procedure.6. Secure urinary drainage bag below the level of the bladder and keep off the floor. Coil extra tubing and secure.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Focused Care at Westwood
8702 Course Drive Houston, TX 77099
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions while performing pressure ulcer treatment on 11/5/25. These failures could place residents at risk of cross-contamination and development of infection.Finding include:Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE REDACTED]. Resident #1 had diagnoses which included history of neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation (bowel movements that are infrequent, hard ,dry or difficult to pass), , orthostatic hypotension (sudden drop blood pressure), bacterial infection, unspecified, cognitive communication deficit need for assistance with personal care.Record review of Resident #1's quarterly MDS assessment, dated 10/20/2025, Section C (Cognitive Patterns) reflected BIMS score was 04 which indicated severely impaired cognitively. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #1's functional status revealed he was dependent with supervision of staff with bed mobility, transfer, and toilet use. Further review revealed Resident #1 had a supra pubic Foley catheter.Record Review of Resident's #1's care plan dated 9/28/2025 reflected I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days.Observation on 11/5/25 at 11:59 AM, revealed Resident #1 lying in bed, a EBP sign was posted inside the room. LVN A entered Resident #1's room without donning PPE and performed pressure ulcer treatment to Resident #1. Interview with the LVN
A on 11/5/25 at 12:30 PM revealed she forgot to don PPE. LVN A said she realized she should have donned PPE to protect the resident and herself for infection. She knew not donning PPE could cause infection. LVN A said she would be more careful. In an interview with the DON on 11/5/25 at 5:15 PM, she stated any resident who had wounds, contact isolation, Gastrostomy tube feeding, or Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted inside the head of Resident #1's bed, which explained what PPE was to be worn and for what task
the PPE was to be worn for. She stated any contact with a resident with pressure ulcer required the use of gown and gloves. She stated the staff received training on the use of Enhanced Barrier Precautions.
Record review of the facility's policy revised, 04/01/2024, on Enhanced Barrier Precautions, reflected the following: Policy Statement: Enhanced barrier precautions (EBPs) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes, EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO or who have open wound or indwelling medical device.Record review of CDC guidelines reflected: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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FOCUSED CARE AT WESTWOOD in HOUSTON, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HOUSTON, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOCUSED CARE AT WESTWOOD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.