A list of the most recent deficiencies for Focused Care of Waxahachie. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-30 | 2023-09-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-08-30 | 2023-09-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-17 | 2023-07-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-13 | 2023-03-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-13 | 2023-03-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-13 | 2023-03-14 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-03-13 | 2023-03-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-27 | 2023-01-25 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-27 | 2023-01-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-27 | 2023-01-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-01-18 | 2023-01-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-12 | 2023-01-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-21 | 2023-01-03 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-27 | 2022-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-12 | 2022-12-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-13 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-13 | 2022-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-13 | 2022-11-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-06 | 2021-08-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-06 | 2021-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-06 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-06 | 2021-08-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-08-04 | 2021-08-11 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-04 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-08-11 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-06-06 | 2019-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-06 | 2019-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-06 | 2019-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-06 | 2019-07-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-06-06 | 2019-07-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-06 | 2019-07-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-06 | 2019-07-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-06 | 2019-06-21 | N |
