Focused Care At Webster

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed

on 10/2/2025, and no concern noted. Resident #2 was placed on 1:1 monitoring until evaluated by psychiatrist for further direction on care. Resident #2 RP was notified of resident current status by social worker on 10/2/2025. Resident # 2 physicians was notified of current status by DCO on 10/2/2025.

Resident #1 and #2 care plans were updated by MDS Nurse on 10/2/2025. DON trained all staff on rounding and supervision on residents to be completed on 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025.Identification of Residents Affected or Likely to be AffectedOn 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025Facility's Plan to ensure compliance quickly DON will provide in-service to all staff on abuse policy and will be completed on 10/3/2025. Staff will not provide direct care until training is completed. DON will provide training for all staff on redirecting resident that wanders into other resident's room and to notify the charge Nurse immediately. DON trained Charge Nurse to assess the residents, notify the DON and Administrator and to monitor residents. Training to be completed on 10/3/2025. DCO will review residents that wander daily in IDT meetings to determine changes to where

they wander to and determine if they need to revise their plan of care. Daily rounds will be conducted by the IDT during focus rounds to identify any concern with residents that wanders and discuss the concern with administrator. Social worker to contact resident #1 Rp to discuss plan of care to be completed 10/3/2025.

The medical Director was notified of the immediate jeopardy on 10/2/2025 by the administrator. The medical director reviewed abuse and neglect policy and made no changes to the policy on 10/2/2025. Any staff member not available for training will not assume any job assignment until training is completed. Staff will identify residents with inappropriate behaviors such as sexual comments, wandering that poses a safety concern, or aggression. If a resident experiences inappropriate behaviors we immediately place them on a 1:1. Psych is then consulted to provide guidance on the behavior and to assist with a plan of care. IDT will ensure that proper interventions are in place. DCO and/or designee will communicate with staff. DCO and/or designee will monitor process. Monitoring of the plan of removal from 10/04/2025 through10/06/25 included:Record review of P

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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

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care at Webster

17231 Mill Forest Webster, TX 77598

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Plan to ensure compliance quickly #2 will be re-evaluated by the Psychiatry by 10/3/2025. Resident #2 is appropriate for group home as determined by psych services. Referral to group home sent by Social Services on 10.3.25 per family recommendation. The Director of Nurses initiated Inservice on 10/2/25 with all staff. Inservice was on Abuse and neglect, resident rights, Accident and Supervision which was conducted by the Director of Clinical Service. Inservice will be completed by 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025. The Director of Clinical Operations and Designee Assessed all wandering residents to determine if they are wandering into other resident rooms and if they are at risk. Resident assessment completed on 10/3/2025, Social worker completed audit on 10/2/2025 on all residents for inappropriate sexual behavior and none was identified. Medical Director notified of alleged facility noncompliance with ensuring supervision of wandering staff. Reviewed staff training on Resident Abuse, Accident and Supervision on 10/2/2025. No changes with policy will be made at this time. Staff are required to make rounds every 2 hours to monitor and supervise residents. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Audit performed on 10.3.25 by Social Worker and DCO. No residents with inappropriate sexual behaviors were identified. Any staff member not available for training will not assume any job assignment until training is completed. All new hires will be educated on abuse policy, resident monitoring, and supervision. Ad Hoc QAPI completed to review all IJs, interventions and Plan of care taken with IDT and Medical director, all interventions are effective at this time.Mo

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