Focused Care At Linden

reach for the residents.

The EDO said for the residents that could not call out there would be a delay

Record review of the facility policy titled Bedrooms dated revised May 2017 indicated . all residents

all resident rooms were equipped with a resident call system that allowed residents to call for staff assistance .

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prevention and interventions for residents with pressure ulcers.

Completed 2/12/2025 3:00 p.m.

jeopardy to resident health or in-service prior to working their next shift.? safety Validation/Monitoring Tools?

Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25.

Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.

Beginning 02/12/25.

Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.

Beginning 02/12/25.

Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.

The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.

Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated wound care written on 02/11/25.

Record review of Resident #93's skin assessment dated [DATE] completed by DCO P, indicated, .stage 3 pressure injuries x3 (right lateral hip, right thigh and left inner thigh) seen by AWC MD .

Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right thigh .2.2cmx3cmx0.2cm .

Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .left inner thigh .1cmx0.1cmx0.2cm .

Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right lateral hip .4.5cmx1.3cmx0.2cm .

Record review of the facility's Residents with Pressure Injuries provided by the EDO on 02/11/25 indicated seven residents with pressure injuries.

Five residents were included in finalized sample. Resident #11 and Resident #15 had missing documentation of wound care and skin assessments.

Record review of the facility's weekly skin assessment dat[TRUNCATED]

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During an interview on 2/12/25 at 9:43 AM, the ADCO said Resident #7's new PL1 would be submitted to the local authority that day (2/12/25).

During an interview on 2/12/25 at 1:33 PM, the ADCO said Resident #7's PL1 not being updated to reflect her new diagnosis of Bipolar in 2023, resulted in Resident #7 potentially not receiving services that she may have qualified for.

The ADCO said it was also a notification issue to have the Local Authority come in to see if Resident #7 met the criteria and be a part of the care plan meetings.

During an interview on 2/12/25 at 2:18 PM, DCO P said she was covering the facility while DCO Q was out sick. DCO P said she worked at a sister facility as the DCO. DCO P said she was not well versed in PASRR regulations, and she just sat in on meetings at her facility.

During an interview on 2/12/25 at 5:46 PM, the EDO said she would expect the PASRR to be updated timely with any new mental illness diagnosis.

The EDO said Resident #7 could have missed out on PASRR services that she may have qualified for.

Record review of the facility's policy titled PASRR and revised on 11/15/23 indicated . the purpose of the policy was to ensure PASRRs were being obtained and completed timely and accurately .

Follow Texas PASRR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status .

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CRC within 72hours of resident admitting to facility.

The completed PL 1 must also be uploaded into

on the PE once the PE is submitted When discharging a resident to another Nursing Facility, the

mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status.

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During an interview on 02/12/25 at 7:34 p.m., the EDO said the IDT was responsible for the baseline care plan.

She said the baseline care plan had to be completed within 72 hours of admission.

She said any staff member could open the baseline care plan.

She said each department was responsible for their part on the baseline care plan.

She said the SSDD was responsible of given the resident and/or responsible party a copy of the summary.

She said it was important to give them a copy to see if everyone agreed with the plan of care.

She said the responsible party could also add input to the plan of care when they received a copy of the summary of the baseline care plan.

Record review of a facility's Baseline Care Plan policy dated 11/01/2019 indicated .a baseline care plan is required to be completed within 48 hours of admission .the facility must provide the resident and their representative with a summary of the baseline care plan .

Record review of a facility's Comprehensive Care Plan revised 04/25/21 indicated .A Registered Nurse will complete the Baseline Care Plan in the RN's absence in the Clinical reimbursement role . An RN initiates all Care Plans .

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During an interview on 02/12/25 at 7:34 p.m., the EDO said, the nursing staff could do resident's care plans.

She said not one person was responsible for comprehensive care plans.

She said the CRC was responsible for care planning the care areas triggered on the MDS.

She said nursing management should have ensured Resident #15 had an Enhanced Barrier Precaution sign posted in her room.

She said acute care plans like the fall care plans, should be done by the nursing staff.

She said the weight loss care plans should be done by the nursing staff and dietary.

She said the care plans ensured the residents received the best individualized care.

She said it was important to follow the resident's care plan because it was individualized.

She said the IDT should review the resident's care plans to ensure they were comprehensive.

Record review of a facility's Comprehensive Care Plan revised 04/25/21 indicated .Every resident will have an individualized interdisciplinary plan of care in place .

The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MOS 3.0) and CAAS, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission . An RN initiates all Care Plan .The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to .Physician orders .Dietary orders .Skin prevention .Fall Prevention

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During an interview on 02/12/25 at 5:25 p.m., the RCP H, said the RCPs were responsible for bathing and oral care.

She said she had not given Resident #93 a bed bath the times she had her.

She said Resident #93 appeared to require limited assistance for bathing if she could clean from the neck down and peri area.

She said the RCPs should clean all the areas Resident #93 could not reach.

She said Resident #93 should receive three bed baths a week.

She said Resident #93 was African American so she did not know how often her hair should be washed.

She said she could not remember if she offered oral care to Resident #93.

She said oral care was supposed to be provided every shift.

She said Resident #93's wash basin should not have been on the floor.

She said after ADL care was given the wash basin and personal hygiene items were stored in the bathroom or closet.

She said not providing bathing and oral hygiene could lead to infections and skin breakdown.

She said Resident #93 probably was not happy.

During an interview on 02/12/25 at 5:49 p.m., the ADCO said, the RCPs were responsible for resident's ADL care.

She said bed baths should be given as scheduled.

She said oral care should be offered and provided every shift by the RCPs.

She said RCPs should document when the ADL care was provided.

She said it was important to provided oral care for oral hygiene.

She said a bed bath was important for skin health, personal hygiene, and dignity.

She said Resident #93 could feel depressed or down due to not getting a good bed bath and oral care.

During an interview on 02/12/25 at 6:57 p.m., the DCO P said a bed bath should be provided three times a week.

She said oral care should be provided to the residents every shift.

She said Resident #93's wash basin should have been stored in the closet or bathroom.

She said the RCPs was responsible for the resident's ADL care.

She said the nurses should be ensuring it was happening.

She said it was important to provide good hygiene care for odors, skin integrity, and quality of life.

During an interview on 02/12/25 at 7:34 p.m., the EDO said the RCPs were responsible for the resident's ADL care.

She said the charge nurse should ensure it was happening.

She said bed baths and showers were scheduled three times a week or as needed.

She said oral care should be provided every shift and as needed.

She said ADL care was important for proper personal hygiene and dental health.

She said a resident not receiving ADL care probably would not feel right.

During an interview on 02/12/25 at 8:15 p.m., the DCE said the facility did not have a policy on ADL care related to bathing and oral care.

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jeopardy to resident health or shift on the floor. safety Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and

All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee.

Completed 2/12/2025 2:00 p.m.

Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift.

All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.

Completed 2/12/2025 3:00 p.m.

Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? Validation/Monitoring Tools? Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25.

Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.

Beginning 02/12/25.

Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.

Beginning 02/12/25.

Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.?? The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.

Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Rec[TRUNCATED]

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During an interview on 2/12/25 at 1:32 p.m., DCO P said staff Report to the maintenance book if exposed wiring was found on an electronic item in room.

During an interview on 2/12/25 at 1:44 p.m., the Director of Nurses said that residents should not have rubbing alcohol in their rooms as it was against facility policy and it could place the resident at risk of harm if they drank it.

She said that if a resident's bed controls had exposed wiring, then it should be replaced or repaired.

She said that anyone who spotted both issues would be responsible to remove the alcohol or report the bed control wiring.

During an interview on 2/12/25 at 5:01 p.m., the Administrator said all staff and focused care partners who observe resident's rooms should keep them free of any potential hazards such as rubbing alcohol or exposed wiring.

She said that residents could be placed at risk if they drank rubbing alcohol of harm.

She said that electronics that have wiring should be properly maintained, and the inner wires should not be exposed for resident safety.

Record review of the facility policy titled, Incident and Accident, dated 03/1/17 indicated, Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred.

Review each incident report at daily clinical meeting Incident reports are located in the electronic health record and are completed electronically.

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gloves, gown, mask, face shield/goggles) . before and after providing any type of care . after contact

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purpose of this policy is to establish facility guidelines on how and when the facility obtains and

weighed at least weekly for at least 4 weeks .re-admission from hospital or other facility .the

for at least 4 weeks .all residents will have a monthly weight obtained .any resident who experiences a significant weight loss or gain must be placed on the 'Weight Surveillance' program .dietitian recommendation should be implemented .

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During an interview on 02/12/25 at 3:19 p.m., the DPO said the oxygen concentrators were contracted out to a company. He said the contracted company was responsible for the maintenance and cleaning of the resident's oxygen concentrators. He said he knew how to clean the internal filters. He said he did not mind cleaning the internal filters if the staff notified him. He said the facility nurses knew how to contact the contracting company for issues. He said the facility staff could also notify him to contact the contracting company for maintenance. He said the facility did not have a set process on who was solely responsible for the internal filters on the resident's oxygen concentrators.

During an interview on 02/12/25 at 5:49 p.m. the ADCO said the physician order told the nurse how much oxygen the residents were supposed to be on.

She said she expected the residents to be on the ordered amount of oxygen.

She said the LVNs should be documenting on the resident MAR/TAR when the resident used oxygen.

She said the nebulizer masks and nasal cannulas should be stored in a bag when not in use.

She said the LVNs were responsible for storage of the resident's masks and cannulas.

She said the cleaning of the internal filters was the responsibility of the oxygen company.

She said the nurses contact the oxygen company when the filters needed to be cleaned.

She said it was important for infection control.

During an interview on 02/12/25 at 6:57 p.m., DCO P, from a sister facility, said she expected the nursing staff to place the resident on the ordered oxygen amount.

She said she expected the nursing staff to document on the MAR/TAR when a resident was on oxygen.

She said the nursing staff should be storing the resident nebulizer masks and nasal cannulas in a clear bag, when not in use.

She said at her facility, the oxygen company came once a month to service the oxygen concentrators.

She said she did not who was responsible for cleaning the internal filters on the oxygen concentrators at this facility.

Review of the facility's Respiratory policy titled Oxygen Therapy dated 04/2021 indicated . policy of this community to ensure all oxygen administration was conducted in a safe manner . verify there was an order for oxygen administration to include . method of delivery, flow rate, oxygen saturation parameters if indicated . start oxygen flow of rate as ordered . document resident's response to PRN oxygen therapy . date and time of oxygen administration . type of delivery . oxygen rate . assessment of resident's respiration status to include oxygen saturation via pulse oximetry . change the reservoir, oxygen cannula and tubing every 7 days . keep oxygen cannula and tubing used PRN in a plastic bag when not in use . wash filters from oxygen concentrators every 7 days in warm soapy water . rinse and squeeze dry .

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During an interview on 02/12/25 at 6:57 p.m., the DCO P, from a sister facility, said the assist rails required an assessment prior to installation.

She said the assessments were done by the nurses quarterly.

She said the resident had to be able to reposition themselves to qualify for assist rails.

She said she did not know if the facility required an order or consent for assist rails.

She said a resident having assist rails without an assessment was a safety risk.

She said if Resident #1 could harm herself then the assist rails needed to be removed.

During an interview on 02/12/25 at 7:34 p.m., the EDO said, the therapy department and LVNs were responsible for bed rail assessments.

She said bed rail assessment were supposed to be done quarterly and with a significant change in status.

She said a resident needed an order for assist rails.

She said the resident had to be able to utilize or reposition themselves to have assist rails.

She said some days Resident #1 would not get out of the bed but other days she would.

She said it depended on the staff how Resident #1 responded.

She said the nursing staff and therapy department should be determining if a resident no longer needed assist rails.

She said bed rail assessments and a physician's orders were important to make sure the assist rails were appropriate for the resident.

Record review of a facility's Bed Safety policy dated 04/2021 indicated .The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment . To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails .) .

Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment . If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative .

The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .

Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified .

Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails .

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The facility failed to complete annual RCP (facility titles CNA as RCP) competency evaluations for RCP L, RCP O, RCP U, RCP V, and RCP W based on the personnel file review results.

This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Findings included: Record review of the Personnel File Review completed on 02/12/25, indicated RCP L, RCP O, RCP U, RCP V, and RCP W did not have a competency evaluation on file.

The Personnel File Review indicated RCP L's date of hire was 01/07/25, RCP O 12/5/24, RCP U 12/5/24, RCP V 10/17/24, and RCP W 11/21/24.

During an interview on 02/12/25 at 1:44 p.m., the Director of Nurses said that she did not know if the RCP (CNA) competencies had been completed.

She said she could not find them.

She said that the previous Director of Nurses did not file them or indicate where she placed them if she completed them.

She said it was important for Resident Care Providers to have their annual competencies evaluated to ensure they were proficient in the areas of care they provide.

During an interview on 02/12/25 at 5:09 p.m., the Administrator said she did not know if the RCP competencies were completed or not.

She said she believed they were completed but they did not have documented proof to provide at the time the interview was conducted .

Record review of the facility policy titles Competency of Nursing Staff dated 04/2020, indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

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During an interview on 02/12/25 at 6:57 p.m., the DCO P, from a sister facility, said the nurses were responsible for ordering resident's medications.

She said the resident's medications should be ordered at least a week before they ran out.

She said the medications were ordered in the facility's chart system.

She said it was important for the resident's medication to be given because it was a doctor's order.

She said the doctor prescribed the medication for a reason to manage a diagnosis.

She said missed doses caused the illness to not be managed.

She said the DCO and ADCO should be overseeing this process.

During an interview on 02/12/25 at 7:34 p.m., the EDO said she expected the nurses to order the resident's medication timely.

She said the resident's medication should be ordered through the facility's chart system.

She said it was an electronically process.

She said the resident's medication needed to be ordered as need or within 7 days of the medications running out.

She said it depended on what diagnosis the medication was treating, how the missed does affected them.

She said the nursing management should be monitoring this process.

Record review of a facility's Ordering and Receiving Non-Controlled Medications dated 06/2024 indicated .medications and related products are received from the pharmacy on a timely basis .ordering medications from the pharmacy .

Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy .

Repeat medications (refills) are written on a medication reorder form or by peeling the reorder tab from the prescription label and placing it in the appropriate area on the medication reorder form provided by the pharmacy for that purpose, or requested via the facility's EHR system .

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During an interview on 02/12/25 at 5:49 p.m., the ADCO said when the LVNs entered the physician orders, they should be ensuring an appropriate diagnosis or indication for use was added to the order.

She said the nurse should be ordering bruise monitoring for the resident on an antiplatelet.

She said it was important to monitor the resident on an antiplatelet for bleeding and abnormal bruising.

She said the nurses should order side effect monitoring on an anticonvulsant.

She said she did not know if cognitive awareness was an appropriate diagnosis for the use of Aricept.

She said Aricept was prescribed for residents with dementia.

She said Aspirin 81mg was an antiplatelet but the diagnosis or indication for use should not be antiplatelet.

She said the ADCO should be monitoring the LVN to ensure they were ordering monitoring and orders had appropriate diagnoses.

During an interview on 02/12/25 at 7:34 p.m., the EDO said, the LVNs were responsible for inputting correct diagnoses with the resident ordered medications.

She said the LVNs should also be ordering side effect and bruise monitoring.

She said the IDT should be monitoring the LVNs to ensure this process was being followed.

She said the monitoring should be done by chart audits and during clinical stand-up meeting.

Record review of a facility's General Guidelines for Medication Administration revised 08/2020 indicated .Medications are administered as prescribed in accordance with good nursing principles and practices .

Monitoring of side effects or medication-related problems occurs continually .

Record review of a facility's Ordering and Receiving Non-Controlled Medications dated 06/2024 indicated .Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy.

The written entry includes .

Indication for use .

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During an interview on 02/12/25 at 7:34 p.m., the EDO said the nurses were responsible for BM and SE monitoring.

She said the nurses should order the monitoring and document every shift.

She said the DCO and ADCO should ensure the LVN's were doing it.

She said BM and SE monitoring were important to ensure the residents did not experience ill effects and the desired outcome was achieved.

She said this process should be monitored through chart audits by the DCO and ADCO.

Record review of the facility's Psychotropic Medication Review policy dated 04/2020 indicated .IDT will emphasize the importance of seeking an appropriate dose and duration of each psychotropic medication, with careful assessment as to whether the medication is necessary and pharmacologically appropriate .Reviews of the use of the medications with IDT on monthly basis, during Standard of Care Meeting to determine the continued presence of target behaviors and or the presence of any adverse effects of the medications .

Monitor GDR for success or failure, related to targeted behaviors .

Monitors psychotropic drug use noting any adverse effects .

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During an interview on 2/12/25 at 7:34 p.m., the EDO said she expected physician's orders to be followed by the nursing staff.

She said the nursing management should be monitoring this process.

Record review of a facility's General Guidelines for Medication Administration policy dated 08/2020 indicated .

Medications are administered as prescribed in accordance with good nursing principles and practices .

Medications are administered in accordance with written orders of the prescriber .

Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes .

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what had been circled on the menus, then be served from the always available menu of her

Record review of the facility's policy titled Resident Food Preferences revised July 2017 indicated .

interdisciplinary team . when possible, staff would interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes . if the resident refuses or was unhappy with his or her diet, the staff would create a care plan that the resident was satisfied with . the Food Services Department would offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night .

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staffing issues and the previous DCO quit by text on Thanksgiving night.

The EDO said RCP O's

few days to show her around.

Record review of the facility's policy titled Hand Hygiene dated last revised 10/24/22 indicated . hand hygiene was used to prevent the spread of pathogens in healthcare settings . you should always perform hand hygiene . before applying and after removing personal protective equipment ( e.g. gloves, gown, mask, face shield/goggles) . before and after providing any type of care . after contact with intact skin . after contact with medical equipment or other environmental surfaces that may be contaminated . you must perform hand hygiene after contact with bodily fluids, such as urine .

Record review of the facility's policy titled Bedrooms dated revised May 2017 indicated .

All residents were provided with clean, comfortable, and safe bedrooms . each resident was provided with . a clean, comfortable mattress . bedding that was clean .

Record review of the facility's policy and procedure Enhanced Barrier Precautions, dated April 1, 2024, indicated .

Enhanced Barrier Precautions (EBP) were a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in healthcare settings, including nursing homes . EBP require team members to wear a gown and gloves while performing high-contact care activities with residents . who have open wounds or indwelling medical device . high contact resident care activities . providing hygiene . changing linens . changing briefs or assisting with toileting . device care . urinary catheter .

During an observation on 02/12/25 at 4:00 p.m., a low air loss mattress, a type of specialty mattress, was noted in Resident #93's room.

Several pillows were noted on Resident #93's bed used for offloading.

Record review of an In-Service and Education Record for Chart Reviews for Admission and Readmitted d 02/11/25, was conducted by the DCE indicated the DCO Q (via phone) and ADCO were in attendance.

Record review of an In-Service and Education Record for Wound Care Orders-Admission and Readmission and Wound Care Orders-Wound

675293

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675293 B.

Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Linden 1201 W Houston St Linden, TX 75563

The facility failed to prevent Resident #35 from having rubbing alcohol in his room.

The facility failed to ensure that electrical wires were encased in their protective covering and not exposed for Resident #12

These failures could place residents at risk for injury, harm, and impairment or death.

Findings included:

1.

Record review of Resident #35's Admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE].

His diagnoses included Acute and Chronic Respiratory Failure with Hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, leading to persistently low levels of oxygen in the blood), Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain), Depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning).

Record review of Resident #35's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 which indicated Resident #35 was cognitively intact.

The MDS also revealed, Resident #35, was understood and understands others.

Shows that Resident #35 requires partial assistance with activities of daily living.

Record review of Resident #35's Care Plan revealed a problem initiation on 3/13/2023 Resident #35 has a self-care performance deficit related to cellulitis.

Shows that Resident #35 required partial assistance with his activities of daily living.

During an observation an interview on 2/10/25 at 9:50 a.m., Resident #35 had a bottle of isopropyl 91% rubbing alcohol in his room. He said that it was his alcohol. He said he did not know where he got it from. He said he used it on his skin to clean himself.

During an interview on 2/12/25 at 1:32 p.m., DCO P said residents are not allowed to keep rubbing alcohol in their rooms.

She said there was a risk to residents because they could accidently drink the alcohol, it could poison them.

675293

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675293 B.

Wing 02/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Linden 1201 W Houston St Linden, TX 75563