Health inspection·February 12, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/12/2025 at 10:17 a.m., with LVN C revealed she had been working remotely to help the facility since January 2025. She stated that the way she completed the MDS assessment was by looking at the social worker's assessment as well as the skilled nursing assessments in PCC, but that she did not know the residents and did not go see them before completing and signing off the MDS assessment. She stated that Resident #12 MDS should have been coded differently if the resident had hearing aids and had significant hearing impairment. Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them. Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. Interview on 02/12/2025 at 2:00 p.m., with the CMDS revealed she had been the CMDS since 2019. She stated that when an MDS nurse was out on leave for one facility there would be another MDS nurse covering for the facility, and it was not normally the process for the MDS coordinator to work remotely and not lay eyes on the residents. She stated that the MDS nurse was responsible for ensuring MDS assessment accuracy but in this instance the covering MDS nurse should have left the assessment open for the CMDS to check for accuracy. She stated that a negative outcome for an incorrect assessment could be residents having their needs being unmet by staff. Interview on 2/12/2025 at 2:00pm, with the CMDS revealed that any inaccuracy on the MDS would be the responsibility of the MDS nurse to correct. The CMDS stated that a negative outcome for an incorrect assessment could lead to the resident receiving the wrong treatment, incorrect labs, and the plan of care not being completed as it should. She stated that her expectation was that an anticoagulant should not be included in the MDS if it was not ordered. She stated that the MDS should accurately reflect the resident's complete medical picture. Record review of the facility's Resident Assessment Instrument policy dated last revised September 2010 revealed, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her practicable level of functioning. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 2 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 2 (Resident #16 and Resident #52) of 14 residents reviewed for PASSAR assessments. Resident #16 did not have a new PASSAR level I screening completed or a PASSAR level II screening completed although a diagnosis of mental illness was diagnosed after the admission date. Resident #52 did not have an accurate PASSAR Level 1 screening after Resident #52 was admitted with a negative PASSAR Level 1 screening but had a mental illness. These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. Findings Included: Record review of Resident #165's Face Sheet indicated the resident was a [AGE] year-old male who admitted to the facility with an original admission date of 02/06/2015., an initial admission date of 06/10/2022, and an admission date of 10/07/2024. Resident #156's face sheet revealed a diagnosis of Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) on 05/15/2024. Resident #15 also had others diagnoses of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (complete weakness and completed paralysis of one side of the body), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and Unspecified Dementia (symptoms that affect memory, thinking and social abilities). Record review of Resident #15's Quarterly MDS assessment dated [DATE], revealed an active diagnosis of Anxiety Disorder, Depression, and Psychotic Disorder and a BIMS of 13 which indicates moderate cognitive impairment. Record review of Resident #15's Comprehensive Care Plan revealed a Focus Area that stated that Resident #15 was PASSAR PE negative due to primary diagnosis of dementia, despite diagnosis of MI dated 04/15/2022. Another Focus Area stated Mr. Resident #16 uses antidepressant medication related to Depression dated 01/01/2022. Record review of Resident #15's PASSAR records indicated no mental illness, intellectual disability and/or developmental disability were present on PASSAR I dated 06/10/2022 and Resident #15 did not qualify for PASSAR II or services. On 02/10/2025 at 11:15 AM an interview was attempted with Resident #16 in which the resident refused to be interviewed with state surveyor. On 02/11/2025 at 2:15 PM another additional interview was attempted with Resident #16 in which the resident had refused again an interview again. Observation on 02/10/2025 at 10:30 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 3 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/11/2025 at 10:22 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep. Record review of Resident #52's quarterly MDS assessment, dated January 29, 2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of bipolar disorder (significant mood swings), depression (feelings of sadness and loss of interest), cognitive communication deficit (brain injuries that affect a person's ability to communicate effectively), muscle wasting (loss of muscle mass), lack of coordination, and intestinal obstruction (bowel blockage). Her BIMS score was a 00, which indicated severe cognitive impairment. Record review of Resident #52's care plan dated last revised 02/09/2025 reflected resident was on an antipsychotic medication due to bipolar, dementia. Record review of Resident #52's PASRR Level 1 screening, dated 10/16/2024 conducted by an acute care hospital, reflected Resident #52 was negative for mental illness, intellectual disability, and developmental disability. The PASRR Level 1 screening also indicated that a physician certified the individual is likely to require less than 30 days of Nursing Facility services. On 02/12/2025 at 1:01 PM an interview was completed with the Director Of Nursing (DON) who stated they had been employed with the facility since January 2025. The DON stated that they were unable to provide a description of the policy for PASSAR screenings. The DON stated the importance of PASSAR screenings was to ensure that the residents have their needs met. The DON stated that a PASSAR screening should be provided before admission into the facility. The DON stated that the facility should have provided PASSAR services to a resident with a positive mental illness diagnosis. The DON stated that people outside of the facility provide PASSAR screenings. The DON stated that the DON completes a screening of the resident's documents when residents are admitted to the facility. The DON stated that a negative impact that could result from residents not receiving PASSAR services, was the residents not receiving holistic care. The DON stated she did not know the PASSAR results of Resident #16 because she was DON is new to the facility. On 02/12/2025 at 1:20PM an interview was conducted with the ADM of the facility who has been employed at the facility for 3 months. The ADM stated that the policy for PASSAR screenings was that it should be completed upon admission. The ADM stated that it was important to complete screenings because it was important to know if the resident was PASSAR positive or not. The ADM stated if a resident has a positive diagnosis of Mental illness, the facility needs to ensure that the resident should have the resources for it. The ADM stated that PASSAR screenings were completed by the MDS coordinator with the region. The ADM stated he ensures that PASSAR screenings were completed by the previous facility and if it was not provided at admission, the ADM would reach out to obtain it. The ADM stated a negative impact for the resident if PASSAR services were not provided was that the resident may not have a proper diagnosis and resources. The ADM stated a new PASSAR screening should occur after a change of condition. The ADM stated that Resident #16 had a negative PASSAR screening. The ADM denied being aware of a mental illness diagnosis. On 02/12/2025 at 02:45PM an interview was conducted with the Corporate MDS Coordinator (CMDS) who stated they had been employed with the facility since 2019. The CMDS stated that they completed audits once a month to ensure PASSAR screenings were up to date. The CMDS stated a 1012 audit had not been completed in February yet. The CMDS stated that a form 1012 should be completed and communicated with the doctor to get a new PL1, if a resident had a change of condition. The CMDS stated that if a resident had a diagnosis of Major Depressive Disorder the results should be positive. The CMDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 4 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that the resident should be provided with a level II PASSAR screening and notify local authorities of the results. The CMDS stated a negative outcome that could occur if a resident had a mental diagnosis but did not receive services, was the needs not being met for the resident. She stated that if a resident has a diagnosis of bipolar their PASRR should not say negative on the Level 1 screening. She stated that the facility should have reviewed the PASRR Level 1 and compared it to Resident #52's diagnoses. She stated that a negative outcome for a negative PASRR Level 1 that should have been positive and required a Level 2 screening by the LIDDA could be that the residents' needs went unmet for not receiving needed services. She stated that to ensure PASRR screenings are up to date audits were done once monthly. She stated that there has been a lot of staff turnover and that the MDS coordinator was responsible for checking these. Record Review of Resident Assessment PASSAR dated 11/2023 indicated the purpose of this policy is to ensure PASSAR's are being obtained and completed timely and accurately. This policy listed the following procedures: 1. PASSARs are obtained from referring entity by the admissions department. 2. PL 1s are put in to Simple LTC by the facility CRC within 72 hours of resident admitting to facility. The completed PL 1 must also be uploaded into the resident's EMR. 3. Communicate with LIDDA/LMHA to ensure all active positive PL 1s have a completed PE and upload the PE into the resident's EMR. 4. Review recommended Specialized Services on the PE once the PE is submitted. 5. When discharging a resident to another NF, the facility is responsible for completing a PASSARR for the NF. 6. Follow Texas PASSAR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSAR status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 5 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans. The facility failed to care plan Resident #12's use of hearing aids. This failure could place residents at risk of their needs going unmet. Findings included: Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition. Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN. Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them. Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 6 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, 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 MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary. Event ID: Facility ID: 455591 If continuation sheet Page 7 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 Provide activities to meet all resident's needs. 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 provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities. Residents Affected - Some The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025. This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life. Findings include: Record review of Resident #25's face undated sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses: Type 2 Diabetes Mellitus (a chronic disease that causes a person's blood glucose levels to rise too high) Chronic Pulmonary Edema (a condition where fluid accumulates in lung tissues, making it difficult to breathe), Acute Respiratory Failure with Hypoxia (acute impairment in gas exchange between the lungs and the blood), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), and Anxiety Disorder (mental disorder characterized by significant and uncontrollable feeling of anxiety and fear that affect daily life). Record review of Resident #25's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #25's activity preferences of strong importance to him were: listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, going outside when the weather is good, and participating in religious services and practices. Record review of Resident #25's Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 12, indicating intact cognition. Record review of Resident #25's Comprehensive Care Plan focus dated 1/17/2025 regarding activities revealed Resident #25 attended most events, but also liked to do individual activities in his room. Resident #25's goal was to continue to participate in at least 4 activities per week. Interventions included posting calendars in the resident's room, reminding and encouraging the resident, thanking the resident for participating, allowing the resident to refuse to participate [in activities], and promoting the resident's love of music and storytelling with staff and other residents. Record review of Resident #31's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), Muscle Weakness, Pulmonary Fibrosis (a condition in which the lungs become scarred over time causing breathing difficulties), need for assistance with personal care, and difficulty walking. Record review of Resident #31's Comprehensive Care Plan initiated on 4/27/2022, revealed the focus regarding activities to be self-directed activities. Resident #31's goal regarding activities was to continue to do Bible studies with other residents through the next review date. Interventions included posting activity calendars in the resident's room, assisting the resident with activities when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 8 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 he agrees to participate, and praising and thanking the resident for attending an activity. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #31's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #31 had a BIMS score of 15, indicating intact cognition, a very important activity preference of participating in religious services or practices, and a somewhat important activity preference of going outside when the weather is good. Residents Affected - Some Record review of Resident #42's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Type 2 Diabetes with Diabetic Autonomic (Poly)Neuropathy (a chronic disease that causes a person's blood glucose levels to rise too high; damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time), Disorder of the teeth and supporting structures, muscle weakness, and Depression. Record review of Resident #42's admission MDS assessment dated [DATE], revealed having books, newspapers, and magazines to read, and listening to music he likes as being very important activity preferences. Record review of Resident #42's Comprehensive Care Plan initiated on 10/13/2022 and revised on 12/27/2023, revealed the resident's activity-related focus to be attending activities of his choice and that the resident will speak his mind and let you know when something is wrong. Resident's #42's activity related goal was to continue to participate in at least 3 activities per week. Interventions included posting an activity calendar in the resident's room, reminding and encouraging the resident daily, promoting the resident's activity ideas and ability to express himself, and the resident's joy and talent in playing the piano, singing, and doing artwork such as drawing. Record review Resident #42's Quarterly Activity Participation Review dated 11/27/2024 revealed the resident attends most large events. The resident's favorite activity and interest were smoking and cooking. The resident's activity-related focuses, goals, and interventions remained the same. Record review of Resident #42's Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 15, indicating intact cognition. Observation and interview 2/11/2025 at 10:11AM, revealed Resident #42 sitting in a chair at the foot of his bed watching a game show on television. Resident #42 expressed boredom and disinterest in watching television, but stated this was something to do to pass the time as there was nothing else to do. Resident #42 stated the activities offered at the facility are not good or of interest to him. The resident stated that lately no activities have been offered. The resident stated that the facility's activity director was fired, and no one had assumed activity duties The resident stated that prior to the activity director's termination, the activity calendar was not being followed. The resident stated that occasionally they played BINGO, but it had been a while. Resident #42 stated the activities program has always been inconsistent and unorganized. The resident stated that suggestions for activities and activity spaces go ignored. Resident #42 stated that he would like more community involvement. He stated that pet therapy and church services stopped because the providers were not allocated a specific time or space to provide the services. Resident #42 stated that the residents need more than occaisonal parties. He stated the residents need activities that enhance their well-being and morale, and that promote positive feelings toward facility staff. Resident #42 stated life at the facility is the same every day, with most residents spending their time watching television with no socializing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 9 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the facility on 2/10/2024, through 2/12/2024, from approximately 9AM-4PM daily, revealed no formal activities being provided to the residents. Observation of the facility activity room on 2/11/2025 at 3PM, revealed no coordinated activities being offered. The television in the activity room was on with 2 residents quietly watching without conversation or interaction with each other. No staff were present in the activity room. It did not appear as if any activity had been provided immediately prior to observation or that any activity was being set up or coordinated in the activity room to be provided following observation. The activity room was orderly and appeared undisturbed. The activity room contained a bookshelf with approximately 20 books, one jigsaw puzzle, and a few videos and audio books. The extra-large, printed activity calendar posted in or near the activity room was observed to be for January 2025, not February 2025. In an interview on 2/11/2025 at 10:59AM, Resident #25 reported the facility was not offering activities as the facility had no AD on staff. The resident stated that the scheduled Valentine's Day party had been cancelled. The resident stated that the last time the residents were provided with an activity was 2 weeks prior, when they were given popsicles. In an interview on 2/11/2025 at approximately 1:15PM, Resident #31 stated the facility was not offering activities. The resident stated that it had been about 2 weeks since any activity was provided. In an interview on 2/12/2025 at 11:16AM, the ADM stated the activity director position is currently vacant as the FAD abruptly vacated the position without notice. The ADM stated that the FAD's last physical day of work was on 1/22/2025. The ADM stated that he and a former hospitality aide had been providing impromptu activities for the residents following the departure of the FAD until the former hospitality aide also vacated her position. The ADM stated that the former hospitality aide's last day of employment with the facility was on 2/7/2025. In an interview on 2/12/2025 at 12:45PM, LVN A stated that she is a Charge Nurse and has been employed with the facility for 4 years. LVN A said the last formal activity provided for the residents was on 2/7/2025. The activity was conducted by a former hospitality aide who no longer works at the facility. LVN A stated the therapy staff have been providing activities for the residents recently. LVN A stated the offering of activities to residents is very important because it gives the residents motivation. LVN A stated that any complaints or suggestions made by residents to her regarding activities would be typically shared during their morning meetings. LVN A said the FAD discontinued her employment with the facility 2 weeks ago. LVN A said she is unsure of who is responsible for making sure the activity calendar has been followed since the FAD left. LVN A said she doesn't know if activities have been provided as listed on the activity calendar. In an interview on 2/12/2025 at 12:50PM, the COTA said she has been employed with the facility for 2 years. The COTA stated that the therapy department staff have been assisting with activities. The COTA stated that the therapy staff help set up games and puzzles for the residents in the activity room, and the therapy room is always open to residents. The COTA stated therapy staff do not provide scheduled activities for the residents. The COTA stated the last formal activity provided to the residents was on 2/7/2025. The COTA stated the quality of activities offered to the residents could be better, but she believes this will improve once a new activity director is hired and an activity calendar is established. The COTA stated there were no scheduled activities being offered on this day to her knowledge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 10 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 2/12/2025 at 12:50PM, the PTA stated she has been employed with the facility for 2 years. The PTA said the therapy department staff have been helping with activities when they can. Their assistance consists of setting up activities and supporting the residents. In an interview on 2/12/2025 at 12:50PM, the RD stated he has been employed with the facility for 2 months. The RD stated the therapy staff have been providing impromptu activities for residents when they can. The RD said these activities are not scheduled and the therapy staff are not responsible for following the activity calendar. The RD said therapy staff assist with setting up activities in the activity room. The RD stated activities are an important because they promote positivity, give residents something to do, improve residents' quality of life, and provide opportunities to socialize. In an interview on 2/12/2025 at 12:55PM, the ADM stated the residents complained about the lack of activities during the Resident Council meeting on 2/5/2025. The ADM stated the lack of activities was due the vacant activity director position. The ADM stated that he is in the process of hiring a new activity director. The ADM stated that he plans to continue to use other staff members to assist with activities until a new activity director is hired. The ADM stated that activities would be provided as scheduled and as listed on the activity calendar, except for the evening activities, as there are no staff available in the evening to conduct activities. The ADM stated that he recently hired HA. HA's first day of employment was on 2/10/2025. The ADM stated that HA will also help with resident activities. The ADM acknowledged that some scheduled activities have been missed, but stated that the facility is in their rebuilding stage and he expects things to improve. In an interview on 2/12/2025 at 1:01PM, HA stated that she began working at the facility this week. Her scheduled hours are 8AM-5PM. HA stated that her duties include passing out ice to the residents twice a day, assist residents with smoke breaks, assist with making residents' beds as needed, and assisting with passing and picking up meal trays as needed. HA stated that she was not aware that her duties would include assisting with activities. HA stated that she has not assisted with activities this week. HA stated that she has not been formally trained or certified as activity personnel. HA stated the benefits of activities is that they keep residents active, they can provide a form of exercise, and it allows residents to interact with each other. HA said the lack of activities for residents could cause a loss of interest in life and isolation. In an interview on 2/12/2025 at 1:04PM, the IDON stated that he has been employed with the facility for 2 months. He said that he doesn't pay attention to the activities offered to residents. He stated that the FAD was believed to be successfully carrying out the activity program for residents, but that was not be the case. The IDON stated that the residents were dissatisfied with the inconsistency of activities and the types of activities offered by the FAD. The IDON stated that the ADM is in the process of hiring a new activity director. The IDON stated that he has not assisted or provided activities for the residents. The IDON stated the benefits of activities include social enrichment, engagement, and improved quality of life. He said the lack of activities for residents could cause depression and isolation. Record review of the facility's activity calendars for January 23, 2025, through February 12, 2025, revealed the following scheduled activities: January 23, 2025: 8:30am Daily Chronicle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 11 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 9:45am-Daily Devotion Level of Harm - Minimal harm or potential for actual harm 11am-Karaoke 1pm-In room visits Residents Affected - Some 2pm-Resident Council Meeting 3:30pm-UNO Game 6:30pm-Table Puzzles 7:30pm-Activity Cart January 24, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 10:30am-S&C 1pm-In room visits 2pm-Birthday Party 3:30pm-Jewelry Art 6:30pm-Table Puzzles 7:30pm-Activity Cart January 25, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Table Puzzles 1pm-In room visits 2pm-LPT 3:30pm-Make a Word Game 6:30pm-Table Puzzles 7:30pm-Activity Cart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 12 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 January 26, 2025 Level of Harm - Minimal harm or potential for actual harm 8:30am-Daily Chronicle 9:45am-Daily Devotion Residents Affected - Some 11am-TBS TV in the Sunroom 1pm-In room visits 2pm-Church Service 3:30pm-Church 6:30pm-Table Puzzles 7:30pm-Activity Cart January 27, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Tea Party 1pm-In room visits 2pm-Spelling Bee 3:30pm Let's Make a Deal 6:30pm-Table Puzzles 7:30pm-Activity Cart January 28, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Rebus Puzzle 1pm-In room visits 2pm-Crafts & Art 3:30pm-[NAME] Game (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 13 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 6:30pm-Table Puzzles Level of Harm - Minimal harm or potential for actual harm 7:30pm-Activity Cart January 29, 2025 Residents Affected - Some 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Reading Rainbow 1pm-In room visits 2pm-Brush painting 3:30pm-Clue words 6:30pm-Table Puzzles January 30, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-Memory Lane 1pm-In room visits 2pm-Family Feud 3:30pm-Indoor Bowling 6:30pm-Table Puzzles 7:30pm-Activity Cart January 31, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 10:30am-S&C 1pm-In room visits 2pm-Name that Tune (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 14 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 3:30pm-Happy Hour Level of Harm - Minimal harm or potential for actual harm 6:30pm-Table Puzzles 7:30pm-Activity Cart Residents Affected - Some February 1, 2025-February 6, 2025, the activities scheduled were the same as follows: 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-FF N.D. Church 1pm-In room visits 2pm-Dominos Games 3:30pm-Board Games 6:30pm-Table Puzzles 7:30pm-Activity Cart February 7, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am1pm-In room visits 2pm3:30pm6:30pm-Table Puzzles 7:30pm-Activity Cart February 8, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 15 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0679 1pm-In room visits Level of Harm - Minimal harm or potential for actual harm 2pm3:30pm-Spades Games Residents Affected - Some 6:30pm-Table Puzzles 7:30pm-Activity Cart February 9, 2025-February 12, 2025 8:30am-Daily Chronicle 9:45am-Daily Devotion 11am-FF N.D. Church 1pm-In room visits 2pm-Dominos Games 3:30pm-Board Games 6:30pm-Table Puzzles 7:30pm-Activity Cart Record review of the Activity Director job description (revised 11/2020) states in part: Position Summary: To develop and provide a comprehensive holistic resident wellness program that meets the individual interests and capabilities of the resident population. Activities will encompass the body (physical), mind (cognitive), spirit, and social engagement dimensions. Record review of the Activities and Social Services policy and procedures (revised December 2006) states in part: Residents shall have the right to choose the type of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. 3. When the Care Planning Team develops the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. 7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 16 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). Residents Affected - Few The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300. These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections. Findings include: Observation on 2/11/25 at 10:30 AM of the Hall 300 Medication Storage Room revealed the following: 8 Zyno IV Administration sets expired 3/19/2023. 7 Zyno IV Administration sets expired 6/20/2022 1 Stat lock PICC PLUS Catheter stabilizer expired 4/28/2023. 1 Central Line Dressing Kit expired 2/28/2021. In an interview on 2/12/25 at 12:48 PM LVN-A stated, the policy on expired medical supplies was to take them back to medical records department where they get rid of them. She stated the nurses, and the medication aides were responsible for checking the rooms. She said this was important because the supplies may not be good to use, and they could hurt the residents by causing infections if they were used. In an interview on 2/12/25 at 12:54 PM LVN-B stated, the policy for expired medical supplies was to pull them out of the medication storage rooms. She stated the nurses, and the medication aides were responsible for checking the medication rooms. She stated that it was important to do this because otherwise someone could grab the expired supplies and accidentally use them. She stated the negative outcome to using expired supplies was that residents could have side effects and the expired supplies could be damaged and not work properly. In an interview on 2/12/25 at 12:59 PM the DON stated, the policy for expired medical supplies was to throw them out/dispose of them. She stated she was responsible for removing expired supplies. She stated, anyone else who finds expired supplies was also responsible for removing them. She stated it was important to remove expired items because they could have lost integrity and materials could be bad which could cause IV dressings to breakdown and come off. In an interview on 2/12/25 at 1:04 PM the ADM stated, the policy on expired medical supplies was to discard them and the nurse's and the nurse supervisors were responsible for doing that. He stated it was important to discard expired items because they could lose effectiveness and then they would not stick to cover the IV sites. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 17 of 18 Printed: 05/15/2026 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 455591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165 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 0755 Record review of the facility's undated policy labeled Pharmscript-Storage of Medications Policy # 4.1, reflected: Level of Harm - Minimal harm or potential for actual harm Outdated medications are immediately removed from inventory. Residents Affected - Few Expired medications will be removed from the active supply and destroyed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455591 If continuation sheet Page 18 of 18