Health inspection·May 24, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Quality of Life - Dignity revised on 08/2009, indicated Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 2 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet, dated 05/24/2024, revealed Resident #30 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder (mental illnesses that cause constant fear and worry) and neuropathy (numbness or tingling in hands or feet from damaged nerves). Residents Affected - Some Record review of the comprehensive MDS assessment, dated 03/11/2024, revealed Resident #30 had clear speech and was understood by staff. The MDS revealed Resident #30 was able to understand others. The MDS revealed Resident #30 had a BIMS score of 7, which indicated severely impaired cognition. The MDS revealed Resident #30 was taking an antipsychotic and antianxiety medication during the last 7 days of the look-back period. Record review of the comprehensive care plan, initiated on 03/15/2024, revealed Resident #30 was taking an antipsychotic medication related to history of aggression, delusion, and agitation. Record review of the physician orders for Resident #30 revealed the following: o Risperidone (antipsychotic) 0.25mg - give 2 tablet by mouth, which started on 03/28/2024. o Gabapentin (neuroleptic/anticonvulsant) 100mg - give 1 capsule by mouth, which started on 04/02/2024. Record review of Resident #30's Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) for the risperidone, signed by the family on 03/03/2024, revealed the section titled the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications is indicated: was blank. The section had not been filled out. Record review of Resident #30's Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) for the gabapentin, signed by the family on 04/02/2024, revealed the section titled the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications is indicated: was blank. The section had not been filled out. During an attempted interview on 05/24/2024 at 8:55 AM to gather more information, Resident #30's family member did not answer the phone. 3. Record review of the face sheet, dated 05/24/2024, revealed Resident #56 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Record review of the quarterly MDS assessment, dated 05/02/2024, revealed Resident #56 had clear speech and was usually understood by staff. The MDS revealed Resident #56 was usually able to understand others. The MDS revealed Resident #56 had a BIMS score of 14, which indicated no cognitive impairment. The MDS revealed Resident #56 had an active diagnosis of seizure disorder or epilepsy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 3 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the comprehensive care plan, revised 02/16/2024, revealed Resident #56 was taking an antipsychotic medication. Record review of the order summary report, dated 05/24/2024, revealed Resident #56 had an order which started on 02/08/2024, for Vimpat (neuroleptic/anticonvulsant medication) 200 mg - give 1 tablet via gastrostomy tube two times a day for epilepsy. Record review of Resident #56's Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) for the Vimpat, signed by the family on 02/08/2024, revealed the section titled the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications is indicated: was blank. The section had not been filled out. During an interview on 05/24/2024 beginning at 10:07 AM, the ADON stated she was the person responsible for filling out the consent forms. The ADON stated the benefits, needs, and proposed treatment section on the consent form should have been filled out. The ADON stated when she filled out Resident #30 and Resident #56's consent forms she completed them like the prior staff members had been completing them because she had not been trained on how to complete them. The ADON stated it was important to ensure the consent forms were completely filled out to ensure the residents and their families knew why they were getting the medications so they could make an informed decision. During an interview on 05/24/2024 beginning at 11:14 AM, the DON stated the ADON was responsible for ensuring psychotropic consent forms were filled out. The DON stated if a new order was obtained on the weekend or after hours, the charge nurse was responsible for ensuring the consent was filled out, then the ADON was supposed to verify the consent was filled out. The DON stated she was responsible if the ADON was not in the facility. The DON stated she expected psychotropic consent forms to have been filled out completely to include the needs and benefits. The DON stated it was important to ensure the psychotropic consent forms were completely filled out so the residents and families were advised of the risks and benefits of the prescribed medications so they could have made an informed decision. During an interview on 05/24/2024 beginning at 11:33 PM, RN B stated she was responsible for ensuring psychotropic consent forms were filled out when there was a new resident admitting to the facility. RN B stated every part on the consent form should have been filled out. RN B said it was important to make sure the consent forms included the need and benefits so the resident or the family could have understood the purpose of the medication to have made an informed decision. During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated she expected psychotropic consent forms to have been completely filled out. The Assistant Administrator stated nursing management was responsible for ensuring psychotropic consent forms were completely accurately. The Assistant Administrator stated it was important to ensure psychotropic consent forms included the needs and benefits so the family would have known what the medication was for so they could have made an informed decision. Record review of the Psychotropic Medication Review policy, effective date April 2020, did not address psychotropic consent forms. Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 4 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0552 he or she prefers for 3 of 5 residents reviewed for the right to be informed. (Resident's #30, #56, and #60) Level of Harm - Minimal harm or potential for actual harm 1. The facility failed to ensure Resident #60 had a signed psychotropic consent form for Trazodone (antidepressant medication). Residents Affected - Some 2. The facility did not ensure the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication was filled out on the HHSC Form 1012 Consent for Antipsychotic or Neurolept Medication for Resident #30 and Resident #56. These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 05/23/2024, revealed Resident # 60 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, unspecified (disease that destroys memory and other important mental functions), cognitive communication deficit ( difficulty with any aspect of communication that was affected by disruption of cognition), and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the MDS assessment, dated 04/23/2024, revealed Resident #60 had a BIMS of 3, which indicated severe cognitive impairment. The MDS revealed Resident #60 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 04/26/2024, revealed Resident #60 used psychotropic medications (antidepressant). Record review of the order summary report, dated 05/23/2024, revealed Resident #60 had an order, which started on 05/15/2024, for Trazodone (an antidepressant medication). Record review of the MAR, dated 05/23/2024, revealed Resident #60 received Trazodone as ordered by the physician. Record review of the electronic medical record for Resident #60, accessed on 05/23/2024 at 10:00 a.m., revealed no consent forms for Trazodone. During an observation and interview on 05/23/2024 at 8:34 a.m., Resident #60 was sitting in the commons area of the men's secure unit, clothing appears neat and clean. Resident #60 was pleasant during interview but was not able to remember the medications he was taking. Resident #60 stated to ask his wife what medication he took. During a phone interview on 05/23/2024 at 1:10 p.m., Resident # 60's wife stated she gave consent over the phone to the nurse to start Trazodone last week. Resident # 60's wife stated she has no concerns at this time. During an interview on 05/23/2024 at 2:16p.m., LVN E stated she was responsible for completing the psychotropic consent forms, but she got busy and forgot. LVN E stated an informed consent form should have been obtained for an antidepressant medication prior to the medication being administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 5 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN E stated it was important to ensure psychotropic medication consent forms were obtained prior to administering the medications so the resident and family knew the risks and benefits of the medication. LVN E stated the failure of not getting a consent prior to administrating the medication could be detrimental to the resident's wellbeing. During an interview on 05/24/24 at 8:20 a.m., the DON stated the nurses were responsible for ensuring psychotropic consent forms were obtained prior to administering the medications. The DON stated consent form should have been obtained for Resident #60's Trazodone. The DON stated it was important to ensure consent forms were completed prior to administering medications so that resident's and their family were aware of the medication, side effects, risks, and benefits. The DON stated the failure was the resident may not get the medication they need. The DON stated she would monitor by medication review. During an interview on 05/24/24 at 9:18 a.m., the ADON stated the charge nurse was responsible for ensuring psychotropic consent forms were completed. The ADON stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications so the resident was aware of the medication, side effects, risks, and benefits. The ADON stated the failure was possible medication error. During an interview on 05/24/24 at 9:52 a.m., the Administrator stated she expected psychotropic consent forms to be obtained prior to administering psychotropic medications. The Administrator stated nursing management was responsible for monitoring psychotropic consent forms. The Administrator stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications to ensure the residents were informed of the risks and benefits and provided informed consent. The Administrator stated the failure was unnecessary medication maybe given. The Administrator stated she would monitor in the morning meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 6 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to allow residents to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the family for 1 of 1 (Resident #44) resident reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #44 to his attorney within two working days of a request on 11/27/2023 for them. This failure could place residents at risk by causing a negative health impact due to not having continuity of care. Findings included: Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), diabetes, and stroke. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. Record review of a formal letter records request for Resident #44's attorney dated 11/27/2023. The formal letter indicated, enclosed please find an authorization for the release of protected health information. Please provide Resident #44's records electronically within 48 hours of receiving this notice. The formal request also included a signed release form from the power of attorney and the power attorney. During an interview on 5/16/2024 at 1:15 p.m., the paralegal indicated the firm had request medical records in November 2023 and again in April 2024. The paralegal said they had just recently received the medical records approximately 2 weeks ago. During an interview on 5/22/2024 at 8:41 a.m., the DON said she was under the understanding when a medical records request was made, an email with the request was sent to the Chief Nursing Officer. The DON said she was unaware in the corporate level who approves the release or how long the release took to process or if the records were released timely. The DON said the BOM may have more knowledge of the process. During an interview on 5/22/2024 at 9:00 a.m., the BOM she said she had found the request in December 2023 in the medical records room. The BOM said she was unsure why the previous medical records staff member failed to respond to the request. The BOM said she had sent the request to corporate in December 2023. The BOM said when the attorney's office called in April 2024, she again sent the medical records request to corporate for approval. The BOM manager said she had sent the medical records to the attorney in May 2024 in several emails. The BOM office manager said she could not find the email correspondences in December 2023 to the corporate level approver. During an interview on 5/22/2024 at 9:59 a.m., the ADON said she was not sure how the release of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 7 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0573 medical records should occur. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/22/2024 at 10:19 a.m., the Assistant Administrator said when a request was received the request was sent to the corporate level for processing. The Assistant Administrator said when there was a delay in sending the medical records there could be a prolonging of a resolution. Residents Affected - Few Record review of an Access to Medical Records policy dated 4/21/2021 revealed: Each resident has the right to access and or obtain copies of his or her personal and medical records upon request. Procedure: 1. A resident /responsible party may submit his/her request either orally or in writing for access to personal or medical information pertaining to him/her 2. Request will be sent to the Chief Clinical Officer and Director of Regulatory/Risk Management. 4. Access to the resident's personal and medical records will be provided to the resident/responsible party within 7 days (excluding weekends and holidays) of his or her request. 7. The resident, or his/her legal representative, may grant others the right to access the resident's records if such request is made in writing and identifies the information that is to be released and to whom the information is to be released. 9. Electronic Medical Records must be provided in electronic form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 8 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 20 residents reviewed for advanced directives. (Resident #52) The facility failed to ensure Resident #52's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of the face sheet dated 05/22/2024, revealed Resident #52 was a [AGE] year-old male with a diagnose other frontotemporal neurocognitive disorder (an umbrella term for a group of brain disease that mainly affect the frontal and temporal lobes of the brain), cognitive communication deficit (difficulty with any aspect of communication that was affected by disruption of cognition), unspecified psychosis not due to a substance or known physiological condition (mental, behavioral and neurodevelopmental disorders). Record review of the MDS dated [DATE], revealed Resident #52 had a BIMS score of 00, indicating severe cognitive impairment. The assessment indicated Resident #52 had no behaviors or refusal of care. Record review of the care plan dated 02/07/2024, revealed Resident #52 had code status as full code. Record review of Resident #52's physician order summary report, dated 05/22/24, indicated an active physician's order for code status: DNR with an order date 03/04/2024. Record review of Resident #52's OOH-DNR dated 03/04/2024, revealed missing signature of responsible party. During an interview on 05/23/2024 at 3:47 p.m., the Social Worker stated herself and the business office manager were both responsible for ensuring DNRs were accurately completed and documented. The Social Worker stated the DNR was missing a missing signature by the responsible party. The Social Worker stated the failure was the resident would be a full code and that was not his wishes. During an interview on 05/23/2024 at 4:00 p.m., the business office manager stated she was responsible for notarizing the DNR's. The business office manager stated it was important for the DNR to be filled out correctly because it was a legal document. The business office manager stated the failure was if the DNR was not filled out correctly it was invalid. During an interview on 05/24/24 at 8:20 a.m., the DON stated she expected DNRs to be filled out correctly or it was not valid. The DON stated the DNR was important to honor the resident's wishes. The DON stated the failure was not honoring the resident's wishes. The DON stated she would review the DNR's before the family left the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 9 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0578 Level of Harm - Minimal harm or potential for actual harm During an interview on 05/24/24 at 9:52 a.m., the Administrator stated she expected DNRs to be filled out, including signatures and dates. The Administrator stated whoever was filling out the DNR was ultimately responsible for ensuring the DNRs were completed fully. The Administrator stated ensuring the DNRs were completed was important to make sure the resident's and family wishes were honored. The Administrator stated she would monitor during morning meeting. Residents Affected - Few Requested facility's policy for DNR not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 10 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 20 (Resident #40) residents reviewed for resident rights. Residents Affected - Few 1. LVN A video recorded Resident #40 on [DATE] when he was in an emergent situation using her personal device and then shared the video with RN B on [DATE]. 2. RN B shared the [DATE] video recording with the ADON, and the BOM on [DATE]. 3. Resident #23 overheard LVN A having a telephone discussion on her personal cell phone of the video recording on [DATE] of Resident #40 while in a common area on her personal cell phone. 4. LVN A and RN B were in possession of the video recording on their personal devices from [DATE] [DATE]. 5. RN B continued to have a screen shot of the video recording of Resident #40 on her personal cellular device on [DATE]. 6. The facility failed to notify Resident #40 of the video obtained of him during his emergent situation, and the distribution to RN B. An Immediate Jeopardy (IJ) situation was identified on [DATE] 10:38 a.m. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of a face sheet dated [DATE] indicated Resident #40 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses of heart failure, depressive disorder, anxiety disorder, and morbid obesity. Record review of the comprehensive care plan dated [DATE] indicated Resident #40 had a diagnosis of depression which placed him at risk for isolation and mood swings. The goal of the comprehensive care plan indicated Resident #40 would be free from discomfort. The interventions included to allow Resident #40 to voice his feelings and validate them. The comprehensive care plan dated [DATE] indicated Resident #40 uses anti-anxiety medications related to having anxiety. The goal of the care plan was Resident #40 would be free from discomfort. The interventions for Resident #40 included to monitor and record occurrences for target behavior symptoms and document according to the facility protocol. Record review of the Quarterly MDS dated [DATE] indicated Resident #40 understood and was understood by others. The MDS indicated Resident #40's BIMs score was 15 indicating he had no cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 11 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 deficits. The MDS indicated Resident #40 sometimes felt lonely or isolated. Level of Harm - Immediate jeopardy to resident health or safety Record review of a nursing note dated [DATE] at 2:10 p.m., LVN A documented she entered Resident #40's room to deliver groceries he had ordered. LVN A documented she found Resident #40 sitting in his bed unresponsive to verbal stimuli, or tactile stimuli. LVN A documented a sternal rub was performed but Resident #40 remained unresponsive. Resident #40's documented vital signs were temperature of 96.8, heart rate 87, oxygen saturation 84%, and blood pressure of 121/70. The note indicated Resident #40 received an injection of Narcan (opioid reversing medication) and called 911. The note indicated upon EMS arrival Resident #40 was verbally responsive and refused transport to the local hospital. The note indicated the physician was notified at 2:41 p.m. LVN A documented while she was removing the fentanyl patch Resident #40 become unresponsive and was shaking as if he had a seizure. The physician advised to call 911. Residents Affected - Few Record review of a Grievance/Complaint form dated [DATE] indicated RN B documented, resident came to charge nurse at start of shift and asked how resident from across the hall was doing. Charge nurse asked resident what she was talking about, and resident stated that during the smoke break, LVN A was outside with her computer charting and talking on phone and stated while resident was unresponsive that she took a video of resident after medication was given before EMS came back and that she made the resident go to the hospital after the resident refused to go. The resident said that the nurse told the residents outside smoking that she saved his life and that the resident had taken too much medication that he ordered online. The charge nurse again asked this resident what was said during lunch in her room she stated the resident refused to go to the hospital and that a video was taken during the time before the resident was taken to the hospital. Record review of a Resident Grievance/Complaint Investigation Report Form dated [DATE] at 8:10 a.m., indicated RN B was the complainant. The form indicated an unnamed resident had approached her stating a video recording without permission was illegal and asked how she could know this was not happening with other residents. The unnamed resident said a resident was videoed unconscious. The form indicated to describe your findings of the incident and the response was the video was present. The form indicated the recommendations/corrective actions were to in-service all staff on HIPPA, and abuse/neglect. The form indicated the ADON completed and signed this form, and the assistant administrator signed the form [DATE]. Record review of a witness statement form dated [DATE], RN B's telephone statement was obtained and witnessed by the Regional Director of Clinical Services. The form indicated LVN A made the video to allow the physician to visualize how Resident #40 was behaving. The form indicated LVN A initially indicated she had not sent the video to RN B but then she said she may have sent it to a dayshift nurse. The witness statement form indicated LVN A was asked to delete the video and then was informed a formal investigation was in effect and that she was suspended pending investigation. Record review of a Disciplinary Action Record dated [DATE] indicated LVN A was suspended on [DATE] related to the occurrence on [DATE]. The form indicated the facts regarding the incident were listed as a video taken of an unconscious resident while waiting on emergency medical services and discussing circumstances surrounding other residents' episode and condition with other residents during the resident's smoke time. The form indicated the expectations for the team member was LVN A would not violate HIPPA and a HIPPA violation was not tolerated. The form indicated the corrective action taken was LVN A was suspended pending investigation, HIPPA violations were not tolerated, and pending findings of the investigation termination could occur. The form also had written based on the results of the investigation it had been confirmed that LVN A violated HIPPA for Resident #40. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 12 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of an in-service dated [DATE] indicated the DON provided training regarding the policy and procedure related to Abuse, Neglect, Mistreatment, Exploitation, Involuntary Seclusion, and Misappropriation of resident property. The in-service also covered employee standards of conduct which includes the standard for prohibiting abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. The in-service also included HIPPA and HIPPA violations. Review of the in-service revealed RN B, BOM, and ADON were among the employees in-serviced. Record review of the in-serviced policy named Abuse dated 2017 indicated the purpose of this policy was to ensure that each resident had the right to be free from any type of Abuse, Neglect, Intimidation, involuntary seclusion/confinement, and or Misappropriation of Property .Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals. Training: All employees are required to be trained in issues related to abuse prohibition practices. Prevention: .Each employee receives the standards of conduct which includes the standards for prohibiting abuse or neglect of a resident, and the reporting of any suspected abuse or neglect of a resident. Reporting: The law requires the abuse coordinator/designee, or employee of the facility who believes that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect, or exploitation All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. If the allegation does not involve abuse and the event does not result in serious bodily injury the allegation should be reported within 24 hours. Protection: It is utmost important that residents suspected of being abused, and all other residents must be protected ruing the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. The in-service included the undated, New Hire Orientation Education HIPAA education. The education included HIPAA a federal law that protects individuals' health information and provides privacy rights. The law also describes steps that must be taken to secure confidential electronic protect health information for unintended disclosure through security breaches. A breach is an unacceptable, impermissible, use or disclosure of PHI (personal health information) that comprises the security of privacy of PHI 3. No matter how interesting it seems to you, do not share anyone's PHI with friends or family . 8. Never send any PHI electronically Record review of a witness statement dated [DATE] indicated the Regional Director of Clinical Services wrote she spoke to RN B by phone conversation in the DON's office. The Regional Director of Clinical Services asked RN B to provide a written statement regarding how she was informed Resident #40 discharged to the hospital. RN B indicated she had received a video from LVN A. RN B said Resident #40 was lying in his bed with an oxygen mask on. RN B said she had deleted the video, notified the ADON, and she felt uncomfortable about having the video. RN B said she felt uncomfortable about the video because Resident #40 was not awake and could not have consented to the video recording. During an interview on [DATE] at 6:22 p.m., the DON said she was aware of the video recording of Resident #40 taken by LVN A. The DON said honestly, she had never had anything of this nature happen before, so she reached out to her supervisor the Regional Director of Clinical Services. The DON said upon the arrival of the Regional Director of Clinical Services they had RN B erase the video recording from her phone, they called corporate, and was advised to suspend LVN A during the investigation. The DON said when LVN A came to the facility to work her shift she was advised to come to the office where she was interviewed regarding the videoing of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 13 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #40 and then sending the video to RN B. The DON said LVN A was suspended, and then terminated. The DON said the incident was not reported because corporate failed to advise to report to HHSC. The DON said the facility completed an in-service that indicated to report allegations of abuse. The DON said RN B was not suspended although she failed to report timely to the abuse coordinator. DON said she did not tell Resident #40 of the video because he was in the hospital and when he returned, she had not thought to tell him. The DON said if this had of happened to her, she would want to know. The DON said she should have told Resident #40 of the video. During an interview on [DATE] at 6:25 p.m., the Regional Director of Clinical Services said she had advised the DON and Assistant Administrator how to handle the video recording incident performed by LVN A regarding Resident #40. The Regional Director of Clinical Services said she had requested and observed each LVN A and RN B erase the video recordings from their personal cell phones on [DATE]. The Regional Director of Clinical Services said she had not watched a second deletion of the video from the cell phones deleted sections of photos. The Regional Director of Clinical Services said she was not advised by the [NAME] President of Clinical Services to report this incident to HHSC. During an interview on [DATE] at 6:27 p.m., Resident #23 said she had heard LVN A talking on her personal cell phone about the video. Resident #23 said she did not know who LVN A was talking to on the cell phone. Resident #23 said she was concerned this happened, and voiced she believed the videoing of Resident #40 was not an appropriate choice. During an observation and interview on [DATE] at 6:28 p.m., Resident #40 was sitting up in his bed. Resident #40 was informed by this writer there was sensitive information to discuss with him. Resident #40 agreed to the conversation. Resident #40 after learning there was an employee who videoed him using her personal cell phone on [DATE] when he was unresponsive sat quietly for a moment. Then, Resident #40's eye welled with tears, and he said, I feel violated, this was the first I had heard of the video recording taking place during my emergent situation. Resident #40 said, I was not in control of myself, and I was taken advantage of without my permission. During a telephone interview and an observation on [DATE] at 6:40 p.m., RN B said she was aware of the video recording made by LVN A on Saturday [DATE]. RN B said in the video Resident #40 was not in a condition to be video recorded. RN B said although Resident #40 had a gown on, his gown only went to his upper thigh level, and the video was recorded facing Resident #40 and to his left side. RN B said LVN A sent the video recording to her while she was off duty at her personal residence. RN B said she was unsure why LVN A felt as though she needed to view a video of Resident #40's emergent situation. RN B said she had not shared the video with any until on [DATE] when she informed the ADON, and the BOM of the video recording. RN B said she no longer had the video, but she had a screen shot of the video remaining on her personal cell phone. RN B provided this screen shot. During an observation of this screen shot, in the center of the screen shot was the circled arrow indicating there was a video, the video was sent on Saturday, and Resident #40 was sitting upright in his bed, his head was back, and he had a non-rebreather oxygen mask on his face. During a telephone interview on [DATE] at 7:14 a.m., LVN A said she was in the habit of using her personal cell phone to record videos and take photographs of residents to send to the physician. LVN A said she had video recorded Resident #40 with the intent to send to his physician in so that the physician could visualize Resident #40's situation. LVN A said she never sent Resident #40's physician the video although this was the purpose. LVN A said she sent the video of Resident #40 to RN B thinking because she was Resident #40's daytime nurse she should be aware of what happened to Resident #40. LVN A said the video was deleted when she was called in the DON's office on [DATE]. LVN A said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 14 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few she would not feel anything if she was video recorded during an emergency. LVN A said when asked why she was acting as a videographer instead of a nurse in an emergency she said she had done what she could for Resident #40, and she was waiting on the EMS to arrive. LVN A said she had never thought of the video again, and she said she does not feel as though she had done anything wrong. LVN A said the video taping of a resident was not considered abuse. During an interview on [DATE] at 7:30 a.m., the BOM said she was made aware of the video of Resident #40 on [DATE]. The BOM said the ADON shared with her the existence of the video of Resident #40. The BOM said she viewed the video with the ADON and then said to the ADON that they would have to reach out to a higher management level to instruct how to handle the incident. The BOM said although she does not actually handle HR matters now the staff tend to still come to her for these matters and this was her reasoning behind viewing the video. The BOM said she had RN B screenshot the video of Resident #40 for the DON to have to use for her investigation. The BOM manager said she did advise the DON the videos should be deleted from the recently deleted files as well. The BOM said there was a risk the video was spread on social media platforms that disappear in minutes, and since the video was on personal cell phone devices these devices were in the employees' personal homes and could have been viewed there as well. The BOM said Resident #40's rights were violated, and she would feel violated if this happened to her. During an interview on [DATE] at 7:42 a.m., the ADON said she was working the day Resident #40 was in an emergent situation [DATE]. The ADON said she left her duties and come to help LVN A with the situation. The ADON said she notified the DON and then the DON reached out to the Regional Director of Clinical Services. The ADON said the DON was informed by the Regional Director of Clinical Services she was in route to the facility and would arrive in 3 hours. The ADON said when LVN A arrived at the facility to start her shift she was called to the DON's office. The ADON said LVN A was then suspended on [DATE]. The ADON said she had viewed the video on RN B's cellular device on [DATE]. The ADON said there was not a reason for LVN A to make a video of Resident #40. The ADON said as nurses we were not taught to video during an emergent situation. The ADON said she was aware the nurses at times had sent pictures of resident's wounds to the physician's cell phone to evaluate. The ADON said she would not feel safe in this environment and if this happened to Resident #40 it could happen to anyone. During an interview on [DATE] at 9:48 a.m., the floor tech said there was never a time videoing a resident would be appropriate. The floor tech said videoing a resident against their knowledge was a privacy issue. During an interview on [DATE] at 9:50 a.m., the transportation driver said she had heard about the video of Resident #40. The transportation driver said she believed videoing recording a resident was a HIPPA violation. During an interview on [DATE] at 9:53 a.m., LVN C said she had made photographed a resident's wounds or a leg and sent the pictures to the physician. LVN C said she used her personal cell phone, but she said her personal cell phone has a lock on it and could not be accessed by others. LVN C said she had never made a video of a resident in an emergent situation, and she would never make such a video saying, I know better. LVN C said she had not been informed not to take photographs of residents. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 10:38 a.m. The Assistant Administrator was informed of the Immediate Jeopardy. The Administrator was provided with the IJ template on [DATE] at 10:39 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 15 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 The facility's plan of removal was accepted on [DATE] at 3:48 PM and included the following: Level of Harm - Immediate jeopardy to resident health or safety Action: LVN A who recorded Resident #40 with her personal phone was suspended on [DATE] and terminated [DATE]. Residents Affected - Few Allegations for Residents #40 were self-reported on [DATE] by the Assistant Administrator and will be investigated. Resident #40 has been notified as part of the investigation. Safe Surveys will be conducted by Social Service Director and AD. Any negative findings have been reviewed and acted on accordingly. Completed [DATE]. Self-report that was completed for Resident #40 will be reviewed by RVP/RDCO for areas of further need. Completed [DATE]. Regional Nurse provided education to the MDS nurse/designee on abuse, neglect, exploitation policy and procedure, HIPPA, not utilizing personal cell phones to record residents in vulnerable situations because this could be considered abuse therefore she was allowed to train other staff. The MDS nurse/designee will in-service Staff prior to the next shift worked. Staff will not be allowed to work until education has been completed. All staff expected to be in service by [DATE]. Any staff member not in serviced by completion date will be in serviced prior to their next scheduled shift. a. Abuse neglect exploitation policy and procedure. b. HIPPA c. Not utilizing personal cell phones to record residents In-service provided to Administrator/DON by Regional Nurse on when to report abuse, what could be considered abuse such as recording residents in vulnerable situations. Resident #40 was physically assessed by Treatment Nurse. No adverse finding. Completed [DATE]. RN B provided with 1:1 in service on reporting any incident that could be considered reportable immediately to the Abuse Coordinator/designee provided by Regional Nurse. Licensed Clinical Social Worker from counseling services has evaluated Resident #40. Completed [DATE]. Daily Focus Care rounds will be completed by management staff and Weekend Manager on Duty to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 16 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents are receiving appropriate care and treatment. Focus Care rounds reviewed with department heads/Manager on Duty. Completed [DATE]. The Medical Director has been notified by DON of the immediate jeopardy and reviewed current policy and procedures for abuse/neglect. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the abuse/neglect policy and procedures. [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: o Record review of LVN A's personnel file, accessed on [DATE], revealed she was suspended pending investigation on [DATE] and terminated on [DATE]. o Record review of self-report from the facility, undated, revealed the incident was reported to the state agency on [DATE]. o Record review of the safe survey interviews, dated [DATE] at 1:15 PM, revealed no concerns of abuse or further incidents of staff recording residents on their personal phone. o Record review of Resident #40's progress notes, dated [DATE] at 12:11 PM, revealed the Treatment Nurse completed an emotional and physical assessment on Resident #40. o Record review of an in-service, dated [DATE], revealed the RDCO conducted an in-service training with RN B, which included all incidents that can be considered reportable to the state must be reported to the administrator immediately. If you are unsure always err on the side of caution and notify the administrator. o Record review of the written statement dated [DATE], from the Licensed Clinical Social Worker revealed Resident #40 was provided services. o Record review of the In-service and education record, dated [DATE], conducted by the RDCO revealed the MDS Coordinator was provided education on the abuse and neglect policy and procedure to included: abuse, neglect, exploitation, HIPPA. The description of training revealed Residents will not be videoed or have pictures taken without consent. No exceptions. Staff will not use personal phones to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 17 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 capture, video, or picture image of any resident in vulnerable conditions as this could be considered abuse. Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Few Record review of the in-service and education record, dated [DATE], revealed the RDCO completed training with the Administrator and DON on when to report abuse and video recording of resident in a vulnerable condition could be reportable. o Record review of the in-service and education record, dated [DATE], revealed the RDCO conducted training with the department heads to review the focused partner program (daily rounds made with residents to address needs). o Record review of the in-service and education record, dated [DATE], revealed staff were provided education on abuse, neglect, exploitation, and HIPPA policy and procedures. The description of training revealed Residents will not be videoed or have picture taken without consent, no exceptions. Staff will not use personal phones to capture video or picture images of any residents in vulnerable condition as this could be considered abuse. o During an interview on [DATE] at 3:58 p.m., the Medical Director stated he was made aware of the IJ situation regarding abuse. The Medical Director stated the plan of removal was discussed and no changes to the policy and procedures were made. o During an interview on [DATE] at 5:46 p.m. with Regional Director of Clinical Operations said she provided in-servicing to the Administrator, Assistant Administrator, DON, ADON, and the MDS coordinator regarding the provider regarding abuse and neglect and HIPPA. The in-service covered when to report and what to report including video recordings. The Regional Director of Clinical Operations said she also assisted with the monitoring tool for the CPR certifications, focus rounds weekly, and other monitoring tools. o During an interview with RN B on [DATE] she indicated she was able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. RN B was able to verbalize refresh training was provided on focused partner rounding on assigned residents. The department heads (DON, ADON, ADM, MDS, BOM, Maintenance, DM, and SW stated videoing a resident in a vulnerable situation could have been a form of abuse. The department heads were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 18 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0583 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During department head interviews on [DATE] between 4:56 PM and 5:38 PM, the Assistant Administrator, DON, ADON, Treatment Nurse (LVN K), BOM, Social Worker, Maintenance Supervisor, Dietary Manager, MDS Coordinator, and AD were able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. They were able to verbalize refresh training was provided on focused partner rounding on assigned residents. The department heads stated videoing a resident in a vulnerable situation could have been a form of abuse. The department heads were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. During staff interviews on [DATE] between 4:56 PM and 5:38 PM, DA V, [NAME] W, Housekeeper G, CNA D, CNA H, CNA M, CNA Q, CNA R, CNA X, CNA Y, MA F, LVN C, LVN E, LVN L, LVN N, LVN P, and RN B were able to verbalize the different types of abuse, when to report abuse, and whom to report abuse. The staff were able to verbalize no video recording or picture image should have been obtained without a resident's consent and personal cell phones should not be used to take photos or videos of residents. The staff stated videoing a resident in a vulnerable situation could have been a form of abuse and should have been reported immediately to the abuse coordinator, which was the Administrator. On [DATE] at 5:55 PM, the Administrator and the Assistant Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 19 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 2 locked units (men's secure unit dining room) observed for homelike environment. The facility failed to ensure residents did not receive meals on serving trays in the dining room during the lunch mealtimes. This failure could result in residents having poor self-esteem and decreased quality of life. The findings included: During a dining observation on 05/20/24 at 12:50 p.m., LVN U was observed leaving the plates on the lunch trays in the men's secure unit. During a dining observation on 05/21/24 at 12:38 p.m., LVN U was observed leaving the plates on the lunch trays in the men's secure unit. During an interview on 05/22/24 at 2:00 p.m., LVN U stated she did not know why they left the plates on the trays. LVN U stated she felt like leaving the plates on the trays was easier to contain the mess. LVN U stated it was important to make the residents feel like they're at home. LVN U stated she did not know what the failure to the residents would be, she would have to ask. During an interview on 05/24/24 at 8:20 a.m., the DON stated she expects staff to remove thee plates off of the trays. The DON stated it was important to provide a homelike environment for the residents and not to be institutionalized. The DON state the failure was not providing a homelike environment. The DON stated she would monitor by making rounds at mealtime. During an interview on 05/24/24 at 9:18 a.m., the ADON stated she expects the plates to be remove from the trays during mealtime. The ADON stated it was important to remove the plates from the trays because you want the residents to feel at home. The ADON stated the failure was a dignity issue. The ADON stated she would reeducate staff. During an interview on 05/24/24 at 9:52 a.m., the Administrator stated she feels like the reasoning for the plates being let on the trays was to keep it contained, so the residents do not pour their meal out or get other residents' food. The Administrator stated she feels it would be more of an issue to take the plates off of the trays because of the resident's cognition. The Administrator stated the failure was not a homelike environment. Record review of the facility's policy titled Quality of Life - Homelike Environment revised on 05/2017, Residents are provided with a safe, clean, comfortable and homelike environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 20 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 4 of 20 residents (Residents #'s 13, 39, 44, and 59), reviewed for care plans. 1)The facility failed to revise and update Resident #13's comprehensive care to reflect his election of hospice services on 5/17/2024. 2)The facility failed to revise and update Resident #39's comprehensive care plan to reflect he was no longer residing on the secured unit as of 5/17/2024. 3)The facility failed to revise and update Resident #44's comprehensive care plan to reflect he was using oxygen continuously. 4)The facility failed to revise and update Resident #59's comprehensive care plan to reflect he was no longer receiving antibiotic and had an PICC (Peripheral Inserted Central Catheter) line since March 2024. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1) Record review of a face sheet dated 5/23/2024 indicated Resident #13 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (memory loss/dementia), malnutrition, and high blood pressure. Record review of the consolidated physician's orders dated May 2024 indicated Resident #13 had an order to admit to hospice under his attending and his hospice physician dated 5/17/2024. Record review of the Quarterly MDS dated [DATE] indicated Resident #13 was usually understood and usually understands. The MDS indicated Resident #13's MDS indicated his BIMS was a 6 indicating he had severe cognitive impairment. The Quarterly MDS did not reflect the election of Resident #13's hospice benefit. Record review of the comprehensive care plan dated 5/23/2024 (after state surveyor intervention) Resident #13 had a terminal diagnosis and was admitted to hospice services and was at increased risk for unavoidable skin issues, weight loss, and overall decline. The goal of the care plan was Resident #13 would have his comfort maintained. The interventions included to notify his hospice provider of any changes in condition, uncontrolled pain, or death. Another intervention was the facility would work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. 2) Record review of a face sheet dated 5/23/2024 indicated Resident #39 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of profound intellectual disabilities, anxiety, seizures, and difficulty swallowing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 21 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Comprehensive Care Plan dated 3/07/2024 indicated Resident #39 resided on the facility memory care unit related to being an elopement risk. The goal of this care plan was Resident #39 maintained safety. The interventions included to provided structured activities. Record review of the Quarterly MDS dated [DATE] indicated Resident #39 was rarely understood, and sometimes understood others. The MDS in Section C-Cognitive Pattern C0700 Resident #39 had a memory problem. The MDS in Section E-Behaviors E0900 Wandering was coded as no behavior was exhibited. During an observation on 5/20/2024 at 8:55 a.m., Resident #39 was sitting in the day room in his wheelchair. Resident #39's room was on the north side of the facility (main halls not the secured unit). 3) Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS indicated in Section J-Health Conditions J1100 indicated Resident #44 had shortness of breath or trouble breathing with exertion, and shortness of breath or trouble breathing when sitting at rest. The MDS in Section O-Special Treatments, Procedures, and Programs Resident #44 was coded as having oxygen therapy while a resident of the facility. The MDS in Section V-Care Area Assessment Summary oxygen therapy was not listed as a triggered area. Record review of the Consolidated Physician's Orders dated 5/2024 indicated Resident #44 was ordered on 3/21/2024 oxygen at 2-3 liters per nasal canula as needed for shortness of breath, desire, or comfort measures. Record review of the Comprehensive Care Plan dated 3/06/2023 failed to indicate Resident #44 had oxygen therapy by way of nasal cannula. During an observation on 5/20/2024 at 2:44 p.m., Resident #44 was lying in bed, he was receiving oxygen therapy by a nasal canula at a rate of 3.5 liters per minute. During an observation on 5/21/2024 at 11:31 a.m., Resident #44 was lying in bed. Resident #44 was receiving oxygen therapy by nasal canula at a rate of 3.5 liters per minute. During an observation on 5/21/2024 at 4:20 p.m., Resident #44 was lying in bed. Resident #44 was receiving oxygen therapy by nasal canula at a rate of 3.5 liters per minute. 4) Record review of a face sheet dated 5/24/2024 indicated Resident # 59 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of a stroke and high blood pressure. Record review of the admission MDS dated [DATE] indicated Resident #59 was understood and he understood others. The MDS indicated Resident #59's BIMS was a 9 indicating moderate cognitive impairment. The MDS in Section I-Active Diagnoses indicated Resident #59 had a urinary tract infection over the last 30 days. The MDS in Section O-Special Treatment, Procedures, and Programs indicated Resident #59 was receiving IV (intravenous therapy) antibiotics. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 22 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a Comprehensive Care Plan dated 3/08/2024 indicated Resident #59 had a PICC (Peripheral Inserted Central Catheter) line and was receiving antibiotic therapy. The goal of this care plan was the infection would be resolved by the end of the antibiotic therapy for Resident #59. The interventions implemented were to administer the antibiotics as ordered and monitor for adverse reactions. Record review of a Medication Administration Record dated March 2024 indicated Resident #59 had a PICC (Peripheral Inserted Central Catheter) line for treatment of an infection for 4 weeks starting on 3/05/2024. During an observation on 5/20/2024 at 9:28 a.m., Resident #59 was preparing to leave his room by way of his wheelchair. Resident #59 had no PICC (Peripheral Inserted Central Catheter) line from either arm, or (intravenous therapy) was there an IV pole in his room. During an interview on 5/24/2024 at 9:16 a.m., the DON said the care plans were reviewed in the morning meeting. The DON said she and the ADON initiated the acute care plans. The DON said the MDS coordinator completed the long-term care plans. The DON said the care plan was updated quarterly and with changes to reflect the correct care the residents require. The DON said a resident could receive inaccurate care when the care plan was inaccurate. During an interview on 5/24/2024 at 9:44 a.m., the ADON said she expected the care plans to be updated as they were discussed in the morning meetings. The ADON said the MDS coordinator updates the care plan in the morning meetings. The ADON said she and the DON complete the acute care plans, and the MDS coordinator completes and revised the long-term care plans. The ADON said inaccurate care plans could cause gaps in care, have misleading information, that could lead to a lack of care and services. During an interview on 5/24/2024 at 10:14 a.m., the Assistant Administrator said she expected the care plans to be updated to ensure the care meets the needs of the resident. The Assistant Administrator said the care plans were a team effort by the DON, ADON, and MDS coordinator. The Assistant Administrator said the care plan accuracy was required to ensure a clear picture of the resident and their care. The Assistant Administrator said the care plans were monitored and revised in the morning meetings. During an interview on 5/24/2024 at 12:28 p.m., the MDS Coordinator said in the morning meeting the acute care plans were addressed and in weekly meetings the care plans were reviewed. The MDS Coordinator said she monitors care plans monthly and quarterly. The MDS Coordinator said the care plans should be accurate, so the wrong care was not provided. Record review of the Comprehensive Care Plan dated 1/20/2021 indicated, that every resident would have an individualized interdisciplinary plan of care in place. A baseline plan of is to meet the resident's immediate needs hall be developed for each resident within 48 hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS The Care Plan is revised every quarter, significant change of condition, annual, or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 23 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure procedures were in place to document a resident's choice regarding CPR for 1 of 20 residents (Resident #114) reviewed for CPR. Residents Affected - Few 1. The facility performed CPR on Resident #114 on [DATE], after failing to accurately assess Resident #114's representative's choice for DNR code status on or before admission. 2. The facility failed to have a system in place to ensure staff maintained accurate CPR certifications. The SW failed to accurately document Resident #1's code status on the social service assessment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] . The IJ template was provide to the facility on [DATE] at 4:43 p.m. While the IJ was removed on [DATE] at 12:13 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of receiving necessary life-saving measures when not desired. Findings included: Record review of a face sheet dated [DATE] indicated Resident #114 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of acute respiratory failure (life threatening disease when there is not enough oxygen in the blood or too much carbon dioxide in the blood stream) with hypoxia (low oxygen levels in the tissues), heart failure, severe kidney disease stage 4 (kidneys not damaged, not working well), and senile degeneration of the brain (loss of memory). The face sheet denoted Resident #114 as desiring to be a Full Code status. Record review of a hospital face sheet dated [DATE] Resident #114 Code Status displayed was a DNR (Do not resuscitate) with the diagnoses of Acute respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide in the blood), heart failure, and stage 4 kidney disease. Record review of a hospital History and physical dated [DATE] indicated Resident #114 was admitted for hypoxic respiratory failure, heart failure and hypertension. The note indicated EMS responded to the nursing facility due to reporting patient was minimally resposnive with cooncern for intermittent episodes of apena. The note indicated Resident #114 had severe decreased responsivness, and EMS was ready to intubate prior to arriving at the emergency room. The note indicated EMS attempted a breathing tube but was unsuccessful. The note indicated the nrusing home contacted the family who stated they wished for Resident #114 not to be intubated, and not be a DNR/DNI status. The note indicated Resident #114 was placed on a non-rebreather mask by EMS with midly improved arousal. The note indicated Resident #114 was seen on the reclining stretcher, she was wearing a non-rebreather mask in place, had an altered mental status with severly decreased responsiveness to voice and touch, was afebrile, nomostensive, tachypenic, and hypoxic receiving oxygen at 10 liters. The note indicated the neurologic assessment indicated Resident #114 was lethaargic. The note indicated critical care was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 24 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 necessary to treat or prevent imminent or life-threatning deterioration of respiratory failure. Level of Harm - Immediate jeopardy to resident health or safety Record review of a 5-day MDS assessment dated [DATE] indicated Resident #114 was usually understood and usually understands others. The MDS indicated Resident #114's BIMS was an 8 indicating Resident #114's had moderate cognitive impairment. Residents Affected - Few Record review of a Social Services assessment dated [DATE] but signed on [DATE] indicated in Section B Advanced Directives/Code Status indicated Resident #114 was a Full Code status. In the subsection 1A. the box checked indicated the code status had been verified as current, complete, accurate, and to coincide with the residents or resident representatives wishes. Record review of a Baseline Care plan dated [DATE] indicated Resident #114 required cardiopulmonary resuscitation and was considered a full code status e-signed by the ADON on [DATE]. Record review of a progress note dated [DATE] at 9:14 p.m., LVN T documented Resident #114 wishes to be a DNR (Do Not Resuscitate) status. LVN T said she notified social services and indicated Resident #114's responsible party would be at the facility on [DATE] to sign the documents. Record review of a progress note dated [DATE] at 10:29 a.m., indicated the SW documented Resident #114 was just finishing breakfast. The SW documented Resident #114 was a full code at this time. Record review of Emergency Medical Service Run Report dated [DATE] at 8:44 p.m., the report indicated the dispatch received their call at 8:44 p.m., dispatched at 8:44 p.m., was enroute at 8:45 p.m., at the patient at 8:51 p.m. and left the facility at 9:17 p.m. The narrative indicated the medic unit was dispatched for an unconscious patient. The note indicated upon arrival the medic unit found the staff at Resident #114's bedside with a bag valve mask (used in rescue breathing) assisting breathing. The medic unit said the nursing staff said when Resident #114's airway was repositioned she stopped breathing. The medic note documented Resident #114 was a Full Code status although the nursing staff was reaching out to the family. The note indicated Resident #114 had a strong pulse to her wrists, and assisted respirations continued after little to no respiratory effort was found. The note indicated the medic attempted an intubation of an artificial airway. The medic documented while continuing assisted breathing Resident #114 was transferred to the stretcher. The medic documented staff members had Resident #114's responsible party on the phone and the responsible party stated they wanted no invasive procedures such as intubation, no CPR, and the medic documented Resident #114's responsible party just wanted Resident #114 to pass. The emergency room physician advised if the responsible party does not want any measures done it was okay to leave Resident #114 at the facility. The medic documented upon reentering Resident #114's room she had increased breathing efforts, more responsive and was transferred to the hospital. The medic documented Resident #114 left the faciity on a non-rebreather mask at 15 liters of oxygen per minute. Record review of the hospital History and Physical dated [DATE] indicated Resident #114 had a history of hypoxic respiratory failure, heart failure, and high blood pressure. The note indicated the nursing home staff found Resident #114 minimally responsive with intermittent episodes of apnea (when you stop breathing or have no airflow). The note indicated Resident #114 had severe decreased responsiveness. The note indicated the facility contracted the responsible party who stated their wishes were for Resident #114 to be a DNR and a DNI (do not intubate). Record review of a nursing progress note dated [DATE] at 9:42 p.m., LVN T documented at approximately 8:47 p.m., Resident #114's nurse came for her assistance. LVN T documented Resident #114 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 25 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few [NAME] Stoke respirations (abnormal breathing pattern which commonly occurs in patients with decompensated heart failure and neurologic diseases) and she was unable to obtain an oxygenation measurement. LVN T documented she applied a non-rebreather oxygen mask at 25 liters per minute. LVN T documented Resident #114's vital signs were heart rate 66, blood pressure 123/66. LVN T documented shortly after placing the oxygen mask on Resident #114 she stopped breathing. LVN T documented she called a code and 911 was called by another nurse. LVN T documented as soon as the crash cart was in the room, she ambu-bagged Resident #114 with 25 liters of oxygen. The note indicated Resident #114's oxygen rose to 80% with a heart rate of 65. LVN T documented emergency medical services arrived and asked this nurse to continue bagging Resident #114. LVN T documented emergency medical services attempted the placement of an endotracheal tube (breathing tube placed in the trachea) but was unsuccessful. LVN T said she continued to bag Resident #114 with oxygen. LVN T stated a call was placed to Resident #114's responsible party. LVN T documented Resident #114's responsible party said to stop lifesaving efforts. LVN T documented she and the emergency medical services went hands off and after approximately 30 seconds, Resident #114 began breathing. LVN T documented Resident #114 was then transferred to the local emergency room. During an interview on [DATE] at 12:16 p.m., the SW said she left early on [DATE] and was unable to visit with Resident #114 and her responsible party on the day of admission. The SW said she had not since reached out to Resident #114's responsible party since her Resident #114's cognitive state was impaired. The SW said since she had not obtained any signed paperwork from Resident #114's responsible party she placed Resident #114 a Full Code. When asked about the SW assessment completed on [DATE] on admission she marked she validated with the responsible party the desires for their advance directive she said she had not actually spoke to the responsible party. The SW said she should have not documented she had confirmed Resident #114's code status when in fact she had not done so. The SW said when not validating a resident's code status a resident could receive life-sustaining measures when not desired. During an interview on [DATE] at 12:44 p.m., the DON said when the facility received referrals the information comes from the corporate care team. The DON said the Administrator received the referral information and the Administrator advised nursing a resident was a pending admission. The DON said she had not reviewed the clinical records of Resident #114 prior to her arrival and was not aware Resident #114 was a DNR status in the hospital. The DON said within 24-48 hours after admission nursing should have had the updated code status for Resident #114. Requested at this time from the DON all nurse competencies for CPR. During an interview on [DATE] at 12:59 p.m., the Assistant Administrator said she was informed of Resident #114 coming to the facility by the centralized admission team. The Assistant Administrator said the centralized admission team validated the admission's financial status, clinical status, and approved for coming. The Assistant Administrator said nursing should have been advised of the hospital code status and reached out to the family on admission. The Assistant Administrator said when a code status was not validated then someone could receive life saving measures when not wanted. During an observation and interview on [DATE] at 1:30 p.m., the DON said the CPR cards were obtained upon hire, but the nursing CPR status was not tracked or maintained after hire. The DON said she would bring the CPR certifications as she obtains them. During an interview on [DATE] at 3:30 p.m., LVN N said she was Resident #114's nurse on [DATE]. LVN N said she went in Resident #114's room to obtain her vital signs when she repositioned her and began checking her vital signs. LVN N said she called Resident #114's name and she opened her eyes, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 26 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Level of Harm - Immediate jeopardy to resident health or safety her breathing as labored. LVN N said she called LVN T in the room and they assessed Resident #114's breathing and indicated she had [NAME] stoke respirations. LVN N said she called 911 and LVN T placed on a non-rebreather mask. Record review of the CPR cards provided indicated the facility failed to provide a current CPR card for anyone other than the DON, ADON, and the treatment nurse. Residents Affected - Few Record review of the Advance Directive policy and procedure dated 4/2020 indicated in accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advanced directions as preferences regarding treatment options and include, but not limited to: a. Advance Directives-a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated e. Do Not Resuscitate-indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used . h. Life-sustaining Treatment-treatment that, based on reasonable medical judgement, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but not those that are considered palliative or comfort measures. k. Other Treatment Restrictions-indicates that the resident, legal guardian, health care proxy, or representative does not wish for the resident o receive certain medical treatments. Examples include, but are not restricted to, blood transfusions, tracheotomy, respiratory intubations, etc. 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative 6. Prior to or upon admission of a resident, the Director of Resident Support Services or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . 18. The Director of Clinical Operations or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care 20. Staff will be educated on the advanced directives process and resident's rights annually and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 27 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 https://www.aclsmedicaltraining.com/respiratory-arrest/ accessed on [DATE] revealed: Level of Harm - Immediate jeopardy to resident health or safety Respiratory arrest is a condition that exists at any point a patient stops breathing or is ineffectively breathing. It often occurs at the same time as cardiac arrest, but not always. In the context of advanced cardiovascular life support, however, respiratory arrest is a state in which a patient stops breathing but maintains a pulse. Importantly, respiratory arrest can exist when breathing is ineffective, such as agonal gasping. Residents Affected - Few We often think of cardiac arrest leading to respiratory arrest, but the respiratory system may shut down without the heart's involvement. If the nerves and/or muscles are not capable of supporting respiration, a patient may enter respiratory arrest. One example of this is in the disease amyotrophic lateral sclerosis (Lou Gehrigsdisease). If the area of the brain that controls respiration becomes depressed, as might occur in an opioid overdose, the brain does not drive respiration. Another example is a state in which the chest might not be able to physically support respiration. This might occur externally (e.g., with a crush injury to the chest) or internally (e.g., in acute respiratory distress syndrome or tension pneumothorax). It is important to keep these possible causes of respiratory arrest in mind during resuscitation. The first goal is to establish an open airway in the patient. The rescuer should use the tools available to them according to a given situation and as appropriate. For instance, if the patient is found in respiratory arrest in a non-hospital setting, the rescuer may only be able to use basic airway techniques such as head tilt/chin lift or jaw thrust maneuver. Incidentally, the head tilt/chin lift is used when cervical spine injury is not an issue and the jaw thrust maneuver is used when an injury to the cervical spine is suspected or feared. If an oropharyngeal or nasopharyngeal airway device is available, consider using these means to assist in airway maintenance (see A Review of Airways). When you are administering artificial respiration, you are breathing for the patient. Avoid excessive ventilation and make sure that you see the chest rise and fall with breaths. Are you providing sufficient oxygenation? If you have access to supplemental oxygen, use it. You may use 100% oxygen initially, but it is best to titrate the level of supplemental oxygen necessary to achieve blood oxygen levels of 94% or higher (based on pulse oximetry). Likewise, if you have access to quantitative waveform capnography, you can use it to monitor end tidal carbon dioxide. Remember that a person who is in respiratory arrest may enter cardiac arrest at any moment. Therefore, it is important to check for pulses to assess circulation. If the patient enters cardiac arrest at any moment, you should follow the cardiac arrest resuscitation algorithm immediately.J https://www.ncbi.nlm.nih.gov/books/NBK526127/ accessed [DATE] revealed: The respiratory system allows gas exchange between the environment and the body, facilitating the process of aerobic metabolism. Specifically, the respiratory system provides oxygen and removes carbon dioxide from the body. The inability of the respiratory system to perform either or both of these tasks results in respiratory failure. Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia. Type 2 respiratory failure occurs when the respiratory system cannot sufficiently remove carbon dioxide from the body, leading to hypercapnia. Respiratory failure can be classified based on chronicity (i.e., acute, chronic, and acute on chronic). A thorough understanding of respiratory failure is crucial to managing this disorder. If either type of respiratory failure is not identified and addressed early, it will become (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 28 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few life-threatening and lead to respiratory arrest, coma, and death. The approach to adult patients with suspected respiratory failure (both hypercapnia and hypoxic), as well as the diagnosis and treatment of acute and chronic respiratory failure, are discussed in this article. Hypercapnic respiratory failure is defined as an increase in arterial carbon dioxide (CO2) ([NAME])> 45 mmHg with a pH < 7.35 due to respiratory pump failure and/or increased CO2 production. In general, according to the modified alveolar ventilation equation, the PaCO2 level is proportionally related to the rate of CO2 production (VCO2) and inversely associated with the rate of CO2 elimination (i.e., alveolar ventilation) (PaCO2 =VCO2 /VA). The relationship between minute ventilation and CO2 production in response to exercise can be affected by age and pregnancy . Respiratory failure is a syndrome caused by a multitude of pathological states; therefore, the prognosis of this disease process is difficult to ascertain. In 2017, in the United States of America, however, the in-hospital respiratory failure mortality rate was 12%. The case definition used in this study included all diagnosis codes, which included respiratory failure.[2] In-hospital mortality rates for patients requiring intubation with mechanical ventilation for asthma exacerbation, acute exacerbation of chronic obstructive pulmonary disease, and pneumonia were found to be 9.8%, 38.3%, and 48.4%, respectively.[37][38][39] Lastly, the in-hospital mortality rate for acute respiratory distress syndrome was found to be 44.3% http://www.nci.nlm.nih.gov/[NAME]/NBK448165/ accessed on [DATE] revealed: Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by [NAME] and [NAME] Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major causes of mortality, and morbidity in developed countries. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options. This activity highlights the role of the interprofessional team in caring for patients with [NAME] Stokes respiration. Objectives: o Review the etiology of Cheyne-Stokes breathing. o Identify the clinical features of Cheyne-Stokes breathing. o Summarize the evaluation of a patient with Cheyne-Stokes breathing. o Describe the role of the interprofessional team in caring for patients with Cheyne-Stokes respiration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 29 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Access free multiple-choice questions on this topic. Level of Harm - Immediate jeopardy to resident health or safety Go to: Residents Affected - Few Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by [NAME] and [NAME] Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major causes of mortality, and morbidity in developed countries. Unlike obstructive sleep apnea (OSA), which can be the cause of heart failure, Cheyne-Stokes respiration is believed to be a result of heart failure. The presence of Cheyne-Stokes respiration in patients with heart failure also predicts worse outcomes and increases the risk of sudden cardiac death. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options . Introduction Prognosis The presence of this pattern indicates a bad prognosis unless attended promptly. Cheyne-Stokes respiration in the upright position can be an ominous sign of cardiovascular dysregulation . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:43 p.m. The Assistant Administrator was informed of the Immediate Jeopardy. The Assistant Administrator was provided with the IJ template on [DATE] at 4:46 p.m. and a Plan of Removal was requested, The facility's plan of removal was accepted on [DATE] at 10:11 AM and included the following: Plan of Action o Social Service Director reviewed clinical records for all residents to ensure that all residents have their code status documented Beginning on 5-21-24 to be completed by 5-21-24. o Social Service Director or Administrative nurses will continue monitoring to begin 5-22-24. o Treatment Nurse and ADON will ensure all residents that are able to make independent decisions have their wishes appropriately documented. Beginning on 5-21-24 to be completed by 5-21-24. o Social Service Director, Director of Nurses, Administrator and Regional Nurse will contact responsible party of those resident that are unable to make independent decision and ensure that the residents wishes were appropriately documented. Beginning on 5-21-24 to be completed by 5-21-24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 30 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 o Level of Harm - Immediate jeopardy to resident health or safety Social Service Director will be provided In-service education on 5-21-24 by Regional Director of Clinical Operations to include: 1. Advanced Directive policy Residents Affected - Few 2. Validation of code status on or before admission o All Licensed Nursing staff will be provided in-service education beginning on 5-21-24 by DCO or designee which includes: 1. Validation of code status on or before admission 2. How/where to locate code status in PCC 3. Documentation of Out of Hospital Do Not Resuscitate order. o All Education/In servicing will be done by 5-21-24. o Newly hired nurses will receive in-service covering Code Status/Resident wishes action plan. o An audit of current CPR status of Licensed Nursing staff has been conducted by Director of Nurses and Business Office Manager on 5-21-24. o Director of Nurses will create a binder that has all Nurses CPR certification and a tracker to indicate when certifications are due to be renewed by 5-22-24. o Medical Director notified of IJ 5-21-24. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: o Record review of the CPR audit report revealed it was completed on [DATE] to ensure all advanced directive wishes were being implemented, followed, and documented in electronic charting system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 31 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 o Level of Harm - Immediate jeopardy to resident health or safety Record review of the in-service dated [DATE] conducted by the Regional Nurse revealed The Social Worker was provided education on the policy for advance directive to include validating code status before or on admission. Residents Affected - Few o During an interview on [DATE] at 11:03 a.m., the SW said upon admission she would verify with the family member or the resident when applicable their code status wishes. The SW said if the decision was for a DNR status then the SW would provide the appropriate paperwork then for the resident or responsible party to complete. The SW said she would then upload the DNR in the computer system after the completion, have a nurse obtain the physician's order, and ensure the computer system reflected the code status. The SW said then quarterly she would evaluate with the resident or family member the desired code status. o Record review of the in-service dated [DATE] conducted by the DON revealed all nursing staff were provided education on the DNR policy which included All admissions code status will be validated prior to or upon admission; Resident who are out of hospital DNR must have an order written for DNR; and how to find code status in the electronic charting system. o During interviews on [DATE] between 10:59 AM and 12:08 PM revealed LVN C, LVN E, LVN K, LVN L, LVN O, LVN P, LVN U, LVN Z, LVN AA, RN B, RN S, RN BB, MDS Coordinator, ADON, and DON were able to verbalize the process for validating code status on new admission residents and whom to report changes in code status. The nurses were able to verbalize were to find the current code status in the electronic charting system. o Record review of the Nurse CPR sheets dated January - December, revealed an audit of CPR status for the nurses were completed and tracking sheets were started. o During an interview and record review on [DATE] at 10:57 a.m., the DON said prior to and upon admission she would verify the code status of a new resident and ensure the code status was properly placed in the electronic record. The DON said even after hours and on weekend admissions she would ensure the code status was validated and placed in the computer system. The DON said there was a tracking binder created to ensure all nurses remained CPR compliant. Record review of the CPR binder included the nursing current CPR cards and monthly tracking sheets. During an interview [DATE] at 11:03 a.m., the Medial Director stated he was made aware of the immediate jeopardy situation regarding advance directives. During an interview on [DATE] at 11:14 a.m., the ADON said she would verify code status of a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 32 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few admission prior to or on the day of the admission. The ADON said she would ensure the out of hospital DNR was uploaded, there was a physician's order to reflect the desires of the resident/family, and then ensure the computerized system accurately reflected the desired code status. The ADON said she was now keeping a binder with a tracking method to ensure all nurses had their CPR training current. During an interview on [DATE] at 11:26 a.m., the Assistant Administrator said she was monitoring the advanced directive follow up by the DON and ADON. The Assistant Administrator said as soon as the resident referral was obtained, and the resident was approved for admission the process was to ensure the code status was obtained by reaching out to the family or resident. The Assistant Administrator said a tracking binder had been made to ensure the nurses remained up to date on their CPR certifications, and the facility maintained a copy of the certification. During an interview on [DATE] at 11:30 a.m., the Administrator said he was in constant communication with the Assistant Administrator and the code statuses, and the CPR monitoring would be discussed at least weekly. The Administrator said when he was on-site, he would do random checks to ensure compliance. On [DATE] at 12:13 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 33 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 4 residents reviewed for range of motion. (Resident #215) The facility did not ensure Resident #215 had a contracture prevention device in place for the treatment of his left hand, wrist, and elbow contracture. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. The findings included: Record review of Resident #215's face sheet, dated 05/24/2024, revealed Resident #215 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state) and hemiplegia and hemiparesis affecting left non-dominant side (conditions that cause weakness or paralysis on one side of the body). Record review of the Annual MDS assessment, dated 05/16/2024, revealed Resident #215 had clear speech and was understood by staff. The MDS revealed Resident #215 was usually able to understand others. The MDS revealed Resident #215 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #215 had no behaviors or refusal of care. The MDS revealed Resident #215 had an impairment to one side of his upper and lower extremities, which interfered with daily functions and placed Resident #215 at an increased risk for injury. The MDS revealed Resident #215 received no therapy or restorative care. Record review of the comprehensive care plan, last revised on 01/18/2024, revealed Resident #215 had a contracture to his left hand, wrist, and elbow placing him at risk for pain and further immobility to the joint. The interventions included: splint in place per orders. Record review of the order summary report, dated 05/24/2024, revealed Resident #215 had no orders to address the contractures to his left arm, hand, or elbow. During an observation and interview on 05/20/2024 beginning at 3:16 PM, Resident #215 was sitting up in the dining room eating his lunch meal. Resident #215 stated he had just returned from an appointment and was eating his lunch. Resident #215's left arm was contracted with limited range of motion as evidenced by inability to move his arm without resistance. Resident #215 had no device or splint in place. Resident #215 stated his arm had been that way since he had a stroke. During an observation on 05/21/2024 at 9:21 AM, Resident #215 was sitting at the dining room table with his breakfast tray in front of him. Resident #215 had no device or splint in place. Resident #215 was unable to use his left arm, which was tightly held against his chest. During an observation and interview on 05/24/2024, Resident #215 was laying down in the bed with the head of his bed elevated slightly. Resident #215 had no device or splint in place. Resident #215 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 34 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0688 Level of Harm - Minimal harm or potential for actual harm was unable to use his left arm, which was tightly held against his chest. Resident #215 said he had not been getting his splint put on his left arm. Resident #215 said the last time it was applied was on 05/17/2024. Resident #215 said he was supposed to wear the splint every day, and it helped his left arm when the staff helped him apply it. Resident #215 said he had not been working with therapy since he returned from the hospital. Residents Affected - Few During an interview on 05/24/2024 beginning at 9:23 AM, CNA Y said Resident #215 had a brace for his left arm. CNA Y stated Resident #215's brace should have been applied every day. CNA Y said the nurses were responsible for ensuring Resident #215's brace was applied. CNA Y said he had not noticed Resident #215 was not wearing his brace. During an interview on 05/24/2024 beginning at 10:07 AM, the ADON said Resident #215 was cognitively intact and able to make his own decisions. The ADON stated Resident #215 was receiving OT to her knowledge. The ADON stated she did not know if Resident #215 wore a splint regularly. The ADON stated she thought he could have because she had seen him wearing one to his left arm in the past. The ADON said therapy staff were responsible for obtaining a physician's order and initiating devices used for contracture management. The ADON said therapy staff should have made sure that nursing staff were aware when splints or braces should have been applied. The ADON said nursing staff would have been responsible for applying devices if Resident #215 was not receiving therapy services. The ADON stated it was important to ensure devices for contracture management were applied to ensure the contracture did not get worse and to ensure the resident felt better. During an interview on 05/24/2024 beginning at 10:47 AM, the DOR stated Resident #215 was not currently receiving therapy services. The DOR stated he was discharged from therapy services when he discharged to the hospital. The DOR stated she did have plans to pick Resident #215 back up on OT services. The DOR stated prior to discharging to the hospital Resident #215 was wearing an elbow and hand splint to his left arm. The DOR stated nursing staff were aware he was wearing a splint. The DOR stated therapy was responsible for applying the splints when the residents were on caseload. The DOR stated nursing was responsible for applying the splint if they were not receiving therapy services. The DOR stated once a resident was discharged from therapy services, then an in-service was provided to the nursing staff by the therapy staff to train them on how to apply, care for, and remove the splint or brace. The DOR stated there should have been a physician's order for the splint. The DOR said the orders should have been reestablished once they returned to the facility from the hospital. The DOR stated it was important to ensure Resident #215's splint was applied to maintain his functional mobility and prevent the contracture from getting worse. During an interview on 05/24/2024 beginning at 11:14 AM, the DON said the therapy department was responsible for ensuring Resident #215's splint was applied. The DON said Resident #215 was non-complaint at times with allowing staff to apply his splint. The DON said typically restorative nursing would have been responsible for applying a splint if a resident was not receiving therapy services, but they currently did not have a restorative program. The DON said she expected an order to have been placed in the electronic charting system to include: the number of hours the splint should have been worn, skin checks, and when it should have been removed. The DON said it was important to ensure Resident #215's splint was applied to maintain his mobility and prevent a decline in function. During an interview on 05/24/2024 beginning at 11:33 PM, RN B said Resident #215 had a splint prior to coming back from the hospital. RN B said she has not seen the splint since he came back from the hospital. RN B said therapy should have been the one to re-order the splint for Resident #215's contracture management. RN B stated Resident #215 was not a big fan of the splint but understood the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 35 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few importance of wearing the splint. RN B stated she was not the nurse who re-admitted Resident #215 from the hospital, but the nurse should have notified the physician to re-establish the order for his splint if it was not noticed on the hospital discharge orders. RN B said the nursing staff had been provided training on how to apply Resident #215's splint. RN B said an active order in the computer would have alerted the nurses to apply Resident #215's splint. RN B said it was important to ensure his splint was applied to maintain his functional ability and improve his quality of life. During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated she expected the facility staff to ensure Resident #215's splint was applied for contracture management. The Assistant Administrator stated when a resident discharges from the hospital and then returns, she expected an order reconciliation to have been completed. The Assistant Administrator stated the admitting nurse and then nurse management was responsible for ensuring orders were re-established on devices for contracture management. The Assistant Administrator stated it was important to ensure devices were applied for contracture management to prevent the contracture from getting worse. During an interview on 05/24/2024 beginning at 1:14 PM, the Assistant Administrator stated the facility did not have a policy on contracture management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 36 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #13 and Resident #44) reviewed for indwelling urinary catheters and incontinent care. 1. The facility failed to ensure Resident #'s 13 and 44's urinary (foley) catheter was properly secured to his leg. 2. The facility failed to ensure Resident #44 was provided proper incontinent care and catheter care. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. 1) Record review of a face sheet dated 5/23/2024 indicated Resident #13 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (memory loss/dementia), presence of urogenital implants and obstructive (placement of stents) and reflux uropathy (conditions that affect blockage or backward flow of urine) Record review of the consolidated physician's orders dated May 2024 indicated Resident #13 had an order dated 4/03/2024 for a Foley catheter 16 French with a 10 cubic centimeter bulb related to obstructive neuropathy. The physician orders failed to reflect the Foley catheter's need for securement. Record review of the Quarterly MDS dated [DATE] indicated Resident #13 was usually understood and usually understands. The MDS indicated Resident #13's MDS indicated his BIMS was a 6 indicating he had severe cognitive impairment. The MDS in Section GG-Functional Abilities and Goals indicated for toileting hygiene Resident #13 was dependent and the staff completed all the work. The MDS in section H0300 Urinary Continence indicated Resident #13 was always incontinent. Record review of the Comprehensive Care Plan dated 4/03/2024 Resident #13 had a Foley Catheter related to obstructive uropathy (calculus/stones) placing him at risk for infections and pain. The goal of the care plan was Resident #14 would have no symptoms of urinary infection. The care planned interventions included to have a 16 French 10 cc (cubic centimeter) bulb Foley catheter, position the catheter bag and tubing below the level of the bladder and away from the entrance of the room door. The comprehensive care plan failed to address the need to have a securing device to Resident #13's foley catheter. The care plan also included the intervention of the utilization of enhanced barrier precautions. During an observation and interview on 5/20/2024 at 2:42 p.m., RN B said Resident #13's Foley catheter was not secured. RN B said the nurse was responsible for ensuring Resident #13's Foley catheter was secured. RN B said when the Foley catheter was not secured Resident #13 could suffer trauma to his penis. 2) Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 37 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0690 memory loss disease), and obstructive and reflux uropathy. Level of Harm - Minimal harm or potential for actual harm Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS in section GG-Functional Abilities and Goals indicated Resident #44 was dependent of the staff to complete all of the effort of toileting. The MDS in section H-Bladder and Bowel H0100Resident #44 was indicated to have an indwelling catheter and in H0300 to have not rated due to the use of a Foley catheter. Residents Affected - Few Record review of the Comprehensive Care Plan dated 3/06/2023 indicated Resident #44 an indwelling catheter 18 French with a 10 cubic centimeter bulb and was at risk for increased urinary tract infections. The goal of the care plan was Resident #44 would be free from catheter related trauma. The care plan interventions included to check Foley catheter placement, ensure Foley was secured via a Velcro strap to reduce friction/pulling. The care plan interventions also include the utilization of enhanced barrier precautions. Record review of the Consolidated Physician's orders dated May 2024 indicated Resident #44 had a Foley catheter 16 French with 10 cubic centimeters bulb related to obstructive uropathy. Record review of a urinalysis report dated 5/07/2024 indicated Resident #44 had an abnormal urinalysis with white blood cells resulted at 50 with a normal of none, bacteria resulted at few with a normal of none, blood and leukocytes results were moderate with the results should be negative. Record review of the Medication Administration Record dated 5/2024 indicated on 5/07/2024 Resident #44 was ordered Macrobid 100 milligrams one capsule two times daily for 7 days for a urinary tract infection. The Medication Administration Record also indicated on 5/10/2024 Resident #44 was ordered Levaquin 500 milligrams for 7 days for infection. During an observation on 5/20/2024 at 2:44 p.m., RN B said Resident #44 did not have a Foley catheter securing device. RN B said when a Foley catheter was not secured trauma could occur to Resident #44's penis. RN B said she was responsible for ensuring Foley catheters were secured. During an observation on 5/21/2024 at 11:31 a.m., the hospice aide and CNA Y prepared Resident #44 for incontinent care and Foley catheter care. The hospice aide applied her gloves, opened a small package of wipes and took out two wipes, then opened Resident #44's brief, then CNA Y rolled Resident #44 to his left side. The hospice nurse aide saw Resident #44 had a bowel movement. The hospice nurse removed her gloves, walked toward the bedside table when the responsible party handed her another package of wipes and some barrier cream. Then the hospice aide applied another pair of gloves and took the two wipes she previously removed and cleansed Resident #44's anal area. Then the hospice aide removed the dirty brief, opened the clean brief, and placed underneath Resident #44 then the hospice aide applied barrier cream to Resident #44's buttocks. CNA Y rolled Resident #44 onto his back, the hospice aide took two wipes and wiped off Resident #44's top of his penis only. The hospice aide closed Resident #44's brief, replaced the linens and then removed her gloves. The hospice aide failed to clean Resident #44's penis and foley catheter tubing during the Foley catheter care. The hospice aide failed to perform hand hygiene during the incontinent care, nor did she change gloves from dirty to clean. Record review of a Nursing Services-Competency Evaluation Skill/Procedure dated 4/26/2024 indicated the treatment nurse evaluated CNA Y skills for peri/incontinent care male without and with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 38 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0690 catheter. The form indicated CNA Y met the skills. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/22/2024 at 7:03 a.m., CNA Y said the hospice aide failed to change her gloves between dirty and clean while performing incontinent care. CNA Y said the hospice nurse aide also failed to properly clean Resident #44's penis and catheter tubing with catheter care. CNA Y said it was important to change gloves between dirty and clean while performing incontinent care and Foley catheter care to prevent infections. Residents Affected - Few During an interview on 5/22/2024 at 11:22 a.m., the hospice aide said she thought she performed incontinent care well. When the hospice aide was asked about changing the gloves between dirty and clean situations, she agreed she had not. When the hospice nurse aide was asked about performing catheter and had she cleaned Resident #44's penis correctly and cleaned the tubing wiping away from Resident #44's penis opening she said she had not done so. The hospice CNA said she had been checked off on skills annually. The hospice CNA said when not performing incontinent care correctly Resident #44 could get a urinary tract infection. During an interview on 5/22/2024 at 4:55 p.m., the hospice DON she expected the hospice aide to change her gloves between dirty and clean. The DON said she expected Foley catheter care to be performed correctly by cleaning the penis and the catheter tubing away from the opening of the penis. The DON said Resident #44 was at risk for infections when the Foley catheter care was not performed correctly. The DON said she was unaware if Resident #44 had a recent UTI. During an interview on 5/24/2024 at 8:53 a.m., the DON said she expected the nurses to ensure Resident #13 and #44's catheters were secured properly. The DON said she expected this especially with these two residents as their Foley catheters were troublesome to replace requiring physician visits for replacement. The DON said stabilizing the Foley catheter prevents pulling and possible trauma from occurring. The DON said she expected the CNAs to perform incontinent care correctly. The DON said Resident #44 was at high risk for urinary tract infections and had even been septic (life-threatening infection) in the past. The DON said skills check off with the facility staff was annually, but she had not thought to ensure the contracted staff performed skills correctly. During an interview on 5/24/2024 at 9:57 a.m., the ADON said the catheter stabilizing device was a required device to prevent trauma from occurring to a resident. The ADON said the nurses were responsible for monitoring the placement of the securing device during their rounds. The ADON said she expected incontinent care to be performed currently and she would have expected CNA Y to stop the hospice CNA when he saw the hospice aide not performing incontinent care and Foley catheter correctly. The ADON said Resident #44 had been treated recently for a UTI and was at risk for UTIs with improper catheter care. During an interview on 5/24/2024 at 10:04 a.m., the Assistant Administrator said she expected a securing device to be applied for Foley catheters. The Assistant Administrator said when the device was not in place the Foley catheter could pull causing trauma. The Assistant Administrator said the nurses were responsible for ensuring the securing devices were properly placed. The Assistant Administrator said she expected incontinent care to be performed correctly to prevent UTIs. The Assistant Administrator said the ADON was responsible for training of the staff as the infection preventionist, and the DON was responsible for the oversight of the training and spot checking of staff skills. Record review of a Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 indicated the policy of this community that the resident with a urinary catheter will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 39 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0690 provided services in a safe and appropriate manner to minimize the risks of urinary tract complications . Level of Harm - Minimal harm or potential for actual harm Record review of a Perineal Care policy dated 10/01/2021 indicated the policy was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Steps in the Procedure .2. Wash and dry your hands thoroughly 6. put on gloves .9. Use wipe and apply skin cleansing agent. B. Wash perineal area starting with the urethra and working outward. (Note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.) 1. Retract foreskin of the uncircumcised male. 2. Cleanse the urethral area using a circular motion. 3. Continue to wash the perineal area including he penis, scrotum and inner thighs. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the urethra. C. If the resident has an indwelling catheter, hold the tubing to one side and support he tubing against the leg to avoid traction or unnecessary movement of the catheter .11. Remove gloves and discard in designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable .15. Wash and dry your hands thoroughly. Residents Affected - Few Record review of a Hand Hygiene policy dated 8/04/2021 indicated hand hygiene is used to prevent the spread of pathogens in healthcare setting. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub to destroy harmful pathogens, such as bacteria or viruses on the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 40 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that respiratory care was provided consistent with professional standards of practice for 1 of 4 residents (Resident #44) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #44's oxygen was set at 2-3 liters per minute as prescribed by physician. These failures could place residents requiring respiratory care at risk for respiratory infections or complications. Findings included: Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy (blocked or back flow of urine). Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS indicated in Section J-Health Conditions J1100 indicated Resident #44 had shortness of breath or trouble breathing with exertion, and shortness of breath or trouble breathing when sitting at rest. The MDS in Section O-Special Treatments, Procedures, and Programs Resident #44 was coded as having oxygen therapy while a resident of the facility. The MDS in Section V-Care Area Assessment Summary oxygen therapy was not listed as a triggered area. Record review of the Consolidated Physician's Orders dated 5/2024 indicated Resident #44 was ordered on 3/21/2024 oxygen at 2-3 liters per nasal canula as needed for shortness of breath, desire, or comfort measures. Record review of the Comprehensive Care Plan dated 3/06/2023 failed to indicate Resident #44 had oxygen therapy by way of nasal cannula. During an observation on 5/20/2024 at 2:44 p.m., Resident #44 was lying in bed, he was receiving oxygen therapy by a nasal canula at a rate of 3.5 liters per minute. During an observation on 5/21/2024 at 11:31 a.m., Resident #44 was lying in bed. Resident #44 was receiving oxygen therapy by nasal canula at a rate of 3.5 liters per minute. During an observation and interview on 5/21/2024 at 4:20 p.m., Resident #44 was lying in bed. Resident #44 was receiving oxygen therapy by nasal canula at a rate of 3.5 liters per minute. LVN N reviewed the oxygen therapy and said the oxygen was at a rate of 3.5 liters per minute. LVN N said she was not sure of Resident #44's orders and left the room to validate. LVN N returned and indicated Resident #44's oxygen orders were from 2-3 liters per nasal canula. LVN N said when the oxygen was not set according to the physician's orders this could affect the disease process the oxygen was used to treat. LVN N said she was responsible for ensuring oxygen was set at the physician ordered amounts. LVN N said she was notifying Resident #44's physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 41 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/24/2024 at 9:09 a.m., the DON said the nurse was responsible for ensuring the oxygen concentrator was set at the ordered amount. The DON said when not following the physician's orders a resident could become over oxygenated or under oxygenated. The DON said this was monitored by spot checking during rounds. During an interview on 5/24/2024 at 9:49 a.m., the ADON said the nurses should evaluate why the oxygen level was increased and if Resident #44 was now requiring this amount for comfort. The ADON said the nurses were responsible for ensuring the physician's orders were followed for the administration of oxygen. During an interview on 5/24/2024 at 12:30 p.m., the Assistant Administrator said she expected the physician's orders to be followed for oxygen administration. The Assistant Administrator said when the order was not followed the resident could affect the disease the oxygen was treating. The Assistant Administrator said the DON and ADON were responsible for monitoring daily and the nurses were responsible for the implementation and monitoring during their shifts. Record review of an Oxygen Therapy policy dated 4/2021 indicated the policy of this community was to ensure all oxygen administration was conducted in a safe manner. Procedure:1. Verify there is an order for oxygen administration to include: a. method of delivery; b. flow rate; c. oxygen saturation parameters if indicated FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 42 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #215) Residents Affected - Few The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #215. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #215's face sheet, dated 05/24/2024, revealed Resident #215 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state). Record review of the Annual MDS assessment, dated 05/16/2024, revealed Resident #215 had clear speech and was understood by staff. The MDS revealed Resident #215 was usually able to understand others. The MDS revealed Resident #215 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #215 had no behaviors or refusal of care. The MDS revealed Resident #215 received dialysis while a resident. Record review of the comprehensive care plan, last revised on 01/18/2024, revealed Resident #215 received hemodialysis three times per week and had an indwelling shunt in his right forearm. Record review of the Dialysis Communication Record forms for Resident #215, from March 2024, April 2024, and May 2024, revealed Resident #215 had missing dialysis communication forms for the following dates: 4/20/2024, 04/18/2024, 04/16/2024, 04/13/2024, and 03/16/2024. The communication forms further revealed there was no post-dialysis assessment from the facility on 03/30/2024 and 03/14/2024. During an observation and interview on 05/24/2024 beginning at 9:17 AM, Resident #215 stated the facility sent a communication paper to dialysis with him when he went. Resident #215 said he was unsure if the facility staff monitored his dialysis shunt every day. Resident #215 had a gauze dressing that was secured with tape to his dialysis shunt on his right forearm. During an interview on 05/24/2024 beginning at 10:07 AM, the ADON stated the nursing staff were supposed to fill out a dialysis communication sheet before dialysis and after dialysis. The ADON stated the charge nurse for Resident #215 was responsible for ensuring the dialysis communication form was filled out. The ADON stated she had no responsibility for overseeing the dialysis process. The ADON stated it was important to ensure dialysis communication forms were available and completely filled out to ensure the facility has an oversite of his dialysis care and were able to identify any problems or concerns . The ADON stated it was important to maintain continuity of care and communication with the dialysis center. During an interview on 05/24/2024 beginning at 11:14 AM, the DON stated dialysis communication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 43 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forms were supposed to have been completed before Resident #215 attended dialysis and when he returned from dialysis. The DON stated the nurse that was assigned to Resident #215 was responsible for ensure the forms were returned by the dialysis center and the post-dialysis assessment was completed . The DON stated the facility recently hired several new staff members and the nurses were recently changed back to 8-hour shifts so they might have been missed. The DON stated she had been checking the dialysis binder once a week for monitoring but was unsure why those were missed. The DON said it was important to ensure the dialysis communication forms were available and completely filled out, so the staff were able to identify and monitor for changes of condition. The DON stated communication was important for continuity of care. During an interview on 05/24/2024 beginning at 11:33 PM, RN B stated the nurse caring for Resident #215 was responsible for ensuring the pre-dialysis section and post-dialysis section of the dialysis communication form was completed. RN B stated if the communication sheet was not returned from the dialysis center, she would call the dialysis center and have them return it via fax to the facility. RN B stated even if the communication sheet was not returned, she would have completed the post-dialysis assessment, so she was able to document it on the form when it was received. RN B said it was important to ensure the communication sheets were available and completely filled out so facility staff would be able to identify and monitor a change in condition. RN B stated communication was important for continuity of care. During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated she expected the nursing staff to ensure the dialysis communication sheets were available at the facility and filled out entirely. The Assistant Administrator stated the DON was responsible for monitoring the dialysis communication forms. The Assistant Administrator stated it was important to ensure the dialysis communication forms were available and completely filled out, so facility staff were aware of the resident's status and continuity of care. Record review of the Dialysis General Guidelines and Management policy, effective date April 2021, revealed .check access site immediately with resident returns . The policy further included a copy of the Pre/Post Dialysis Communication Form which revealed the nursing facility post-dialysis documentation should have been completed upon the resident's return and placed in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 44 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 20 residents' (Resident #'s 38) reviewed for trauma-informed care. Residents Affected - Few The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 09/12/2023, indicated Resident #38 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), post-traumatic stress disorder ( a mental health condition that can develop in people who experience or witness a traumatic event), anxiety disorder ( condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). Record review of the MDS assessment, dated 02/22/2024, revealed Resident #38 had a BIMS of 00, which indicated severe cognitive impairment. The MDS revealed Resident #38 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 03/09/2023, revealed Resident #38 had post traumatic stress disorder with interventions to alleviate stress and post-traumatic stress disorder triggers. During an interview on 05/23/2024 at 3:47 p.m., the Social Worker stated she was responsible for ensuring trauma assessments were done on admission. The Social Worker stated she did not work at the facility when Resident #38 was admitted and did not realize his trauma assessment was not done. The Social Worker stated the trauma assessment was important, so the staff was aware of Resident #38's history. The Social Worker stated the failure was the staff may not be able to assess Resident # 38 needs. During an interview on 05/24/24 at 8:20 a.m., the DON stated she expected trauma assessments to be done on admission. The DON stated the trauma assessment was the social services responsibility. The DON stated the trauma assessment was important because if the resident has PTSD it could play into his problems. The DON stated the failure of not having a trauma assessment was the resident could harm self or others. The DON stated she would monitor on admission and weekly with the social worker. During an interview on 05/24/24 at 9:52 a.m., the Administrator stated she excepted the trauma assessment to be done on admission. The Administrator stated it was social services responsibility to complete the trauma assessment. The Administrator stated the failure was the staff would not know the triggers and would not be able to provide the best care. The Administrator stated she would monitor during morning meetings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 45 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0699 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Trauma-Informed Care revised on 10/12/2022, indicated This assessment was to be used in conjunction with the initial Social Services Assessment within seven days of admission Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 46 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 73.08 %, based on 19 errors out of 26 opportunities, which involved 3 of 3 residents (Residents #14, #24 and #56) reviewed for medication administration. Residents Affected - Some The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. The facility did not ensure Resident #56 was given Famotidine 20 mg. The facility did not ensure Resident #56 Diclofenac Sodium 1% was applied to one extremity instead of both extremities. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #14's face sheet, dated 05/22/2024, indicated Resident #14 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnosis which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue), type 2 diabetes without diabetic neuropathy (chronic condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure), and vitamin deficiency. Record review of the order summary report dated 05/22/2024 indicated Resident #14 was ordered: Acetaminophen-Codeine 300-600 mg one tablet by mouth TID for pain. Ascorbic Acid 500 mg one tablet by mouth QD for supplement. Cholecalciferol 1,000-unit one tablet by mouth QD for vitamin. Divalproex Sodium 250 (750) mg three tablets by mouth QD for anticonvulsant. Jardiance 10 mg one tablet by mouth QD for antidiabetic. Lisinopril 10 mg one tablet by mouth QD for hypertension. Meloxicam 15 mg one tablet by mouth QD for analgesic. Metoprolol Succinate ER on e tablet by mouth QD for HTN. Montelukast Sodium 10 mg one tablet by mouth QD for antiasthmatic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 47 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0759 Risperidone 2 mg one tablet by mouth QD for Psychosis. Level of Harm - Minimal harm or potential for actual harm Senna 8.6 mg two capsule by mouth QD for constipation. Vitamin B12 ER 1000 mcg one tablet by mouth QD for supplement. Residents Affected - Some Duloxetine 30 mg one capsule by mouth BID for depression. Cyclobenzaprine 5 mg one tablet by mouth TID for muscle spasms. Gabapentin 600 mg one tablet by mouth QID for neuropathy (numbness/tingling hands/feet). Cranberry 400 mg 1 capsule by mouth BID for supplement. Record review of the Medication Administration Audit Report dated 05/22/2024 indicated Resident #14 received his medications as listed: Cyclobenzaprine 5 mg one tablet at 10:14 a.m. Acetaminophen-Codeine 300-600 mg one tablet at 10:15 a.m. Ascorbic Acid 500 mg one tablet at 10:17 a.m. Cholecalciferol 1,000-unit one tablet at 10:17 a.m. Gabapentin 600 mg one tablet at 10:18 a.m. Duloxetine 30 mg one capsule at 10:19 a.m. Divalproex Sodium 250 (750) mg three tablets at 10:23 a.m. Cranberry 400 mg 1 capsule at 10:25 a.m . Jardiance 10 mg one tablet at 10:25 a.m. Lisinopril 10 mg one tablet at 10:26 a.m. Montelukast Sodium 10 mg one tablet at 10:28 a.m. Risperidone 2 mg one tablet at 10:28 a.m. Senna 8.6 mg two capsule at 10:28 a.m. Vitamin B12 ER 1000 mcg one tablet at 10:29 a.m. Meloxicam 15 mg one tablet at 10:29 a.m. Metoprolol Succinate ER on e tablet at 10:29 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 48 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0759 During an observation on 05/20/2024 at 10:14 a.m., RN B prepared and administered Resident #14's medications for administration: Level of Harm - Minimal harm or potential for actual harm Acetaminophen-Codeine 300-600 mg one tablet Residents Affected - Some Ascorbic Acid 500 mg one tablet Cholecalciferol 1,000-unit one tablet Divalproex Sodium 250 (750) mg three tablets Jardiance 10 mg one tablet Lisinopril 10 mg one tablet Meloxicam 15 mg one tablet Metoprolol Succinate ER on e tablet Montelukast Sodium 10 mg one tablet Risperidone 2 mg one tablet Senna 8.6 mg two capsule Vitamin B12 ER 1000 mcg one tablet Duloxetine 30 mg one capsule Cyclobenzaprine 5 mg one tablet Gabapentin 600 mg one tablet Cranberry 400 mg 1 capsule During an interview on 05/21/2024 at 10:57 a.m., RN B stated the medications should have been given between 7:00 a.m.-9:00 a.m. RN B stated medications were given late due to short staff of CNAs and having to assist with getting residents up for breakfast. RN B stated this failure could potentially cause an overdose or adverse effect. 2. Record review of Resident #24's face sheet, dated 05/22/2024, indicated Resident #24 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes without complications (chronic condition that affects the way the body processes blood sugar). Record review of the order summary report dated 05/22/2024 indicated Resident #24 was ordered: Novolog FlexPen Solution 100 unit/ml inject 5-unit Sub Q for Type II Diabetes Mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 49 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Medication Administration Audit Report dated 05/22/2024 indicated Resident #24 received his medications as listed: Novolog FlexPen Solution 100 unit/ml (5 units) at 12:30 p.m. During an observation on 05/20/2024 at 12:28 p.m., RN B prepared and administered Resident #24's medications for administration: Novolog FlexPen Solution 5 units During an interview on 05/22/2024 at 11:05 a.m., RN B stated Resident #24's insulin should have been given at 11:30 a.m. but per her nursing judgment with his blood sugar being 122 and meals were just started being served in the dining room and his hall was served last she waited until trays were being served to residents on his hall. RN B stated his blood sugars were to be held if less than 120 and he was right there at the holding range so if she had of administered the fast-acting insulin it would put him at risk for hypoglycemia (low blood sugar). RN B stated this failure could potentially put him at risk for hypoglycemia episodes. 3. Record review of Resident #56's face sheet, dated 05/22/2024, indicated Resident #56 was a [AGE] year-old-female, originally admitted to the facility on [DATE] with a diagnosis which included paranoid schizophrenia (a type of psychosis that causes people to lose touch with reality and experience disorienting and frightening symptoms). Record review of the order summary report dated 05/22/2024 indicated Resident #56 was ordered: Famotidine 20 mg 1 tablet via G-tube for acid reflux. Diclofenac Sodium 1% ointment apply to right lower extremity BID for arthritis pain. During an observation on 05/21/2024 at 7:57 a.m., RN S was preparing Resident #56's medication for administration. RN S obtained a bottle of omeprazole 20 mg and placed 1 tablet in the cup. RN S finished preparing the remainder of Resident #56's morning medications. The medication label on the ointment read as follows: Diclofenac Sodium 1% ointment apply to right lower extremity BID. RN S went into Resident #56's room and administered the medications via G-tube. RN S applied ointment to Resident #56's right and left extremity. During an interview on 05/21/2024 at 8:24 a.m., RN S stated the medication should be verified with the MAR prior to administering medication. RN S stated if the medication label did not match the physicians order she should have notified the nurse for DON. RN S stated, I really thought the bottle said to compare to famotidine because it's a generic. RN S stated it was important to clarify discrepancies in the medication orders prior to medication administration to ensure Resident #56 get relief acid reflux and prevent medication error. RN S stated this failure could potentially put Resident #56 at risk for aspiration and discomfort. RN S stated should have followed the directions on the box and only applied the ointment to her right lower extremity. RN S stated sometimes Resident #56 complained of left leg pain. RN S stated she should have contacted the MD and got an order to apply ointment to the left leg. RN S stated this failure could cause a drug interaction. During an interview on 05/23/2024 at 4:12 p.m., the DON stated she expected medications to be administered one hour before or one hour after scheduled time. The DON stated RN B should have notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 50 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the MD prior to administering medications. The DON stated she was responsible for monitoring to ensure medications were passed timely along with the nurses by running the medication administering audit every other day and looking on the dashboard on PCC. The DON stated she had noticed the issue in the past and staff were verbally in serviced. The DON stated if that staff member continued to administer medications late a write up was completed. The DON stated the failure of not administering medications on time were not following the physician's order and could cause interactions with other medications and depended on the severity it could lead to death. The DON stated she expected medications to be given per the physician orders. The DON stated nurses should follow the five rights of medication administration. The DON stated the nurse should have compared the medication to the MAR. The DON stated once she realized it was incorrect, she should have ceased the administration. The DON stated RN S should have notified the MD. The DON stated she completed a medication administration pass on last week and there were no issues. The DON stated was important to clarify discrepancies in the medication orders prior to medication administration so medication errors or adverse reactions did not occur. During an interview on 05/23/2024 at 4:44 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated she expected MD orders to be followed. The Administrator stated she expected the 5 rights to be followed by comparing the orders to the MAR. The Administrator stated the DON was responsible for overseeing and monitoring. The Administrator stated it was important to follow the MD orders and administration medications on time to prevent medication. The Administrator stated these failures could potentially cause an adverse reaction. Record review of the facility's policy titled, Administration Procedures for All Medications, revised on 08/2020 indicated, .Medications will be administered in a safe and effective manner 2. Prior to removing the medication from the container: (a) check the label against the order on the MAR Record review of the facility's policy titled, General Guidelines for Medication Administration, revised 08/2020 indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices 4. At a minimum, the 5 rights-right resident, right drug, right dose, right route, and right time should be applied to all medication administration and reviewed at three steps in the process of preparation .11. A schedule of routine dose administration times is established by the facility and utilized on the administration records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 51 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0760 Ensure that residents are free from significant medication errors. 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 ensure that residents were free of significant medication errors for 2 of 3 residents (Residents #14 and #24) reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #14's face sheet, dated 05/22/2024, indicated Resident #14 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnoses which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue), type 2 diabetes without diabetic neuropathy (chronic condition that affects the way the body processes blood sugar), essential hypertension (high blood pressure), and vitamin deficiency. Record review of the order summary report dated 05/22/2024 indicated Resident #14 was ordered: Acetaminophen-Codeine 300-600 mg one tablet by mouth TID for pain. Divalproex Sodium 250 (750) mg three tablets by mouth QD for anticonvulsant. Jardiance 10 mg one tablet by mouth QD for antidiabetic. Lisinopril 10 mg one tablet by mouth QD for hypertension. Meloxicam 15 mg one tablet by mouth QD for analgesic. Metoprolol Succinate ER on e tablet by mouth QD for hypertension. Cyclobenzaprine 5 mg one tablet by mouth TID for muscle spasms. Gabapentin 600 mg one tablet by mouth QID for neuropathy. Record review of the Medication Administration Audit Report dated 05/22/2024 indicated Resident #14 received his medications as listed: Cyclobenzaprine 5 mg one tablet at 10:14 a.m. Acetaminophen-Codeine 300-600 mg one tablet at 10:15 a.m. Gabapentin 600 mg one tablet at 10:18 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 52 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0760 Divalproex Sodium 250 (750) mg three tablets at 10:23 a.m. Level of Harm - Minimal harm or potential for actual harm Jardiance 10 mg one tablet at 10:25 a.m. Lisinopril 10 mg one tablet at 10:26 a.m. Residents Affected - Few Meloxicam 15 mg one tablet at 10:29 a.m. Metoprolol Succinate ER on e tablet at 10:29 a.m. During an observation on 05/20/2024 at 10:14 a.m., RN B prepared and administered Resident #14's medications for administration: Acetaminophen-Codeine 300-600 mg one tablet Divalproex Sodium 250 (750) mg three tablets Jardiance 10 mg one tablet Lisinopril 10 mg one tablet Meloxicam 15 mg one tablet Metoprolol Succinate ER on e tablet Cyclobenzaprine 5 mg one tablet Gabapentin 600 mg one tablet During an interview on 05/21/2024 at 10:57 a.m., RN B stated the medications should have been giving between 7:00 a.m.-9:00 a.m. RN B stated medications were given late due to short staff of CNAs and having to assist with getting residents up for breakfast. RN B stated this failure could potentially cause an overdose or adverse effect. 2. Record review of Resident #24's face sheet, dated 05/22/2024, indicated Resident #24 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes without complications (chronic condition that affects the way the body processes blood sugar). Record review of the order summary report dated 05/22/2024 indicated Resident #24 was ordered: Novolog FlexPen Solution 100 unit/ml inject 5-unit Sub Q for Type II Diabetes Mellitus. Record review of the Medication Administration Audit Report dated 05/22/2024 indicated Resident #24 received his medications as listed: Novolog FlexPen Solution 100 unit/ml (5 units) at 12:30 p.m. During an observation on 05/20/2024 at 12:28 p.m., RN B prepared and administered Resident #24's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 53 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0760 medications for administration: Level of Harm - Minimal harm or potential for actual harm Novolog FlexPen Solution 5 units Residents Affected - Few During an interview on 05/22/2024 at 11:05 a.m., RN B stated Resident #24's insulin should have been given at 11:30 a.m. but per her nursing judgment with his blood sugar being 122 and meals were just started being served in the dining room and his hall was served last she waited until trays were being served to residents on his hall. RN B stated his blood sugars were to be held if less than 120 and he was right there at the holding range so if she had of administered the fast-acting insulin it would put him at risk for hypoglycemia (low blood sugar). RN B stated this failure could potentially put him at risk for hypoglycemia episodes. During an interview on 05/23/2024 at 4:12 p.m., the DON stated she expected medications to be administered one hour before or one hour after scheduled time. The DON stated RN B should have notified the MD prior to administering medications. The DON stated she was responsible for monitoring to ensure medications were passed timely along with the nurses by running the medication administering audit every other day and looking on the dashboard on PCC. The DON stated she had noticed the issue in the past and staff were verbally in serviced. The DON stated if that staff member continued to administer medications late a write up was completed. The DON stated the failure of not administering medications on time were not following the physician's order and could cause interactions with other medications and depended on the severity it could lead to death. During an interview on 05/23/2024 at 4:44 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated she expected the 5 rights to be followed by comparing the orders to the MAR. The Administrator stated the DON was responsible for overseeing and monitoring. The Administrator stated it was important to follow the MD orders and administration medications on time to prevent medication. The Administrator stated these failures could potentially cause an adverse reaction. Record review of the facility's policy titled, General Guidelines for Medication Administration, revised 08/2020 indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices 4. At a minimum, the 5 rights-right resident, right drug, right dose, right route, and right time should be applied to all medication administration and reviewed at three steps in the process of preparation .11. A schedule of routine dose administration times is established by the facility and utilized on the administration records Record review of the facility's policy titled, Administration Procedures for All Medications, revised on 08/2020 indicated, .Medications will be administered in a safe and effective manner FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 54 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 1 kitchen reviewed for sufficient support personnel. The facility did not ensure the lunch meal on 05/20/2024, 05/21/2024, and 05/22/2024 were served on time. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness. Findings included: Record review of the Meal Time Serving Order, sheet undated, indicated breakfast was started at 7:00 a.m. and lunch was started at 12:00 p.m. for the secured men's unit, dining room, women's unit and north hall. During an interview on 05/20/2024 beginning at 9:00 a.m., the Dietary Manager stated breakfast was served at 7:00 a.m. and lunch was served at 12:00 p.m. During an observation on 05/20/2024 at 12:30 p.m., first trays were wheeled to the secured men's unit. The first dining room trays were served at 12:50 p.m. The last trays on north hall were served at 1:45 p.m. During an observation on 05/21/2024 at 12:17 p.m., first trays were wheeled to the secured men's unit. The first dining room trays were served at 12:21 p.m. The last trays on north hall were served at 12:28 p.m. During an observation on 05/22/2024at 7:12 a.m., first trays were wheeled to the secured men's unit. The first dining room trays were served at 7:15 a.m. The last trays on north hall were served at 7:21 a.m. During an interview on 05/22/2024 at 12:14 p.m., the Dietician Consultant stated she expected meals to be served on time. The Dietitian Consultant stated she expected the Dietary Manager to help make sure his staff served meals on time. The Dietician Consultant stated it was important to ensure food was served on time to ensure the resident best interest. During an interview on 05/23/2024 at 1:36 p.m., Dietary Aide CC stated for the past two months there had been an issue with meals served on time. Dietary Aide CC stated the food has been served late because of the lack of staff and available help in the kitchen. Dietary Aide CC stated it was important to ensure food was served on time a to ensure residents did not become sick such as hypoglycemi a (low blood sugar) or lose their appetite. During a telephone interview on 05/23/2024 at 2:15 p.m., [NAME] DD stated for the past two months there had been an issue with meals served on time because staff turnover. [NAME] DD stated it was important to ensure food was served on time because they need to eat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 55 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/23/2024 at 2:30 p.m., the Dietary Manager stated he expected meals to be served on time. The Dietary Manager stated it had been an issue with staff turnover since he became the Dietary Manager back in October 2023 . The Dietary Manager stated he monitored by random spot checks. The Dietary Manager stated staff and residents had reported to him that their food had not been on time . The DM stated it was important to ensure food was served on time because the residents nutrition was important, and it affected their health and behaviors. During an interview on 05/23/2024 at 4:44 p.m., the Administrator stated she expected meals to be served on time. The Administrator stated because of the inexperience in the management position meals been served late had been an issue. The Administrator stated she believed the dietary staff had sufficient staffing but mismanagement of time due to staff not coming in earlier enough to prepare the food had caused this issue. The Administrator stated she was responsible for monitoring and overseeing but the system she currently had in place will be revised. The Administrator stated it was important to ensure food was served on time to prevent illness and it was their right to received meals on time. A request for the facility policy regarding meals served on time was submitted to the Administrator on 05/23/204 at 5:00 p.m. A policy regarding meals served on time was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 56 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meal (breakfast) reviewed for menus. Residents Affected - Few The facility failed to follow the breakfast menu for residents on 05/22/2024 . This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. Findings included: Record review of the daily menu posted outside the kitchen on 05/22/2024 at 7:00 a.m. indicated the breakfast meal scheduled for that day was: oatmeal, sausage patty, waffle. There was no sign indicating a substitution available from the menu. During an observation on 05/22/2024 at 7:05 a.m. of the steam table assembled with food ready to be plated for the breakfast meal indicated there was no sausage or waffle . During an interview on 05/22/2024 at 12:14 p.m., the Dietician Consultant stated she expected the menu to be followed. The Dietician Consultant stated the Dietary Manager should have contacted her and discussed a substitution since there was no sausage or waffle available. The Dietician Consultant stated it was important to ensure the menu was followed to ensure the resident got the correct nutritional value for that day. During an interview on 05/23/2024 at 2:15 p.m., [NAME] DD stated the menu should be always followed. [NAME] DD stated if there was something not available residents should be given a substitute. [NAME] DD stated she had been on vacation and was not aware there was no waffles or sausage available. [NAME] DD stated it was important to follow the menu to prevent weight loss. During an interview on 05/23/2024 at 2:30 p.m., the Dietary Manager stated he expected the menu to be followed. The Dietary Manager stated he was aware that on Friday 5/17/2024 there was enough sausage available to last the following week. The Dietary Manager stated he believed the cook over the weekend had cooked to many sausages. The Dietary Manager stated [NAME] DD had got the breakfast mixed up with Thursday breakfast, but the residents were supposed to still received sausages according to the menu. The Dietary Manager stated he monitored by random spot checks. The Dietary Manager stated he had not noticed any issues in the past. The Dietary Manager stated it was important to ensure menus have been followed to ensure residents were receiving their nourishment. During an interview on 05/23/2024 at 4:44 p.m., the Administrator stated she expected menus to be followed. The Administrator stated there had been times the dietary staff let her know if there was an item not available. The Administrator stated usually someone will go get the item or a substitution would have been available. The Administrator stated she was responsible for monitoring and overseeing but the system she currently had in place will be revised. The Administrator stated it was important to ensure menus were being followed to ensure the resident received their nutrition value. Record review of the facility's policy titled, Preparation of Foods, effective 04/2022 indicated, .food is to be prepared by methods that conserve nutritive value, flavor and appearance .4. All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 57 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0803 recipes in use will be standardized and will be maintained in a file or book accessible to the cooks. The cook is responsible for food preparation using those recipes which reflect the planned menu . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 58 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: 1. Food items were dated. 2. The juice machine spigot was free from a red gooey substance where the juice was dispersed. 3. Muffin pans were free from encrusted black colored grease buildup coating the entire outside and most of the inside surface. 4. The steam pans were stacked with water pooled in between them. 5. The microwave was clean and free of food debris. 6. The stove was clean and free of food debris. 7. Test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. 8. Hair restraints worn. These failures could place residents at risk for foodborne illness. Findings included: During the initial tour observation with the Dietary Manager on 05/20/2024 between 9:00 a.m. and 9:45 a.m., the following was revealed: 1. 3 Muffin pans were free from encrusted black colored grease buildup coating the entire outside and most of the inside surface. 2. 3 small and 3 big steam pans were stacked with water pooled in between them. 3. The juice machine spigot with a thick gooey red substance. 4. Inside the microwave had a black/yellow buildup. 5. Stove had several brown spots with food debris noted. 6. 2 packages of English muffin undated. 7. 1 package of coleslaw undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 59 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0812 8. 4 bags of hashbrowns undated. Level of Harm - Minimal harm or potential for actual harm 9. 1 bag of mixed vegetables undated. 10. 1 bag of sweet potatoes fries undated . Residents Affected - Some 12. Test strips dated 02/2024 and 05/01/2024. During an observation and interview on 05/20/2024 at 9:10 a.m., the Director of Environmental Services came in the kitchen without wearing a hair restraint. The Director of Environmental Services stated she should have worn a hairnet prior to entering the kitchen. The Director of Environmental Services stated, It was a mistake, I was in hurry. The Director of Environmental Services stated it was important to wear to prevent food contamination. During an interview on 05/22/2024 at 12:14 p.m., the Dietician Consultant stated she expected food to be dated when the item was taking out the original packet. The Dietitian Consultant stated the microwave and stove should be cleaned after each meal and as needed. The Dietician Consult stated she expected the juice dispenser to be cleaned per protocol of the juice company. The Dietitian Consultant stated she expected the test strips to be in date and hair nets worn while in the kitchen. The Dietitian Consult stated she expected the pans to be air dried first before stacking. The Dietitian Consultant stated she expected the muffins pans to be replaced and not used. The Dietitian Consultant stated she had noticed these issues in her sanitation audit and had in-serviced staff. The Dietitian Consultant stated there was a daily and weekly cleaning schedule that each staff member should have signed off prior to completing their shift. The Dietitian Consultant stated the Administrator was responsible for monitoring and overseeing in between. The Dietitian Consultant stated these failures mentioned above put residents at risk for food contamination. During an interview on 05/23/2024 at 1:36 p.m., Dietary Aide CC stated whoever removed the item from the original package should have dated the bag. Dietary Aide CC stated the steam pans should have been air dyed first and then stacked. Dietary Aide CC stated everyone was responsible for cleaning. Dietary Aide CC stated whoever use the microwave or stove last should have cleaned it. Dietary Aide CC stated the juice dispenser should be cleaned daily. Dietary Aide CC stated there was a list of what should be cleaned and whoever completed the task should put their initialed by the task. Dietary Aide CC stated these failures could cause a food borne illness. During a telephone interview on 05/23/2024 at 2:15 p.m., [NAME] DD stated the person that took the item out the original packet should have dated the package. [NAME] DD stated the pans should have been dried prior to stacking. [NAME] DD stated the cooks were responsible for cleaning the stove after each use. [NAME] DD stated she had just come back from vacation and the stove was like that when she came in. [NAME] DD stated all staff were responsible for cleaning the microwave and the aides were responsible for cleaning the juice dispenser. [NAME] DD stated these failures put residents at risk for food borne illness. During an interview on 05/23/2024 at 2:30 p.m., the Dietary Manager stated he was responsible for making sure the muffin pans were clean. The Dietary Manager stated it was monitored by inspecting them weekly. The Dietary Manager stated he had replaced the muffin pans but had not brought them out because he been on medical leave. The Dietary Manager stated all staff were responsible for ensuring steam pans were dried prior to stacking. The Dietary Manager stated the stove and microwave should be cleaned after each use and the juice dispenser daily. The Dietary Manager stated he was unaware the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 60 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some test strips had expirations date until surveyor intervention. The Dietary Manager stated hair restraints should be worn prior to entering the kitchen. The Dietary Manager stated there was a cleaning schedule, but no one was assigned to any tasks. The Dietary Manager stated whoever completed the task first should put their initial by it. The Dietary Manager stated he was responsible for monitoring and overseeing by daily rounds and when there was an issue staff was verbally in serviced immediately. The Dietary Manager stated these failures could potentially put residents at risk for food borne illness and contamination. During an interview on 05/23/2024 at 4:44 p.m., the Administrator stated she expected when an item was taken out the original packet it should be dated. The Administrator stated she expected the kitchen staff to dry the items appropriately to ensure that there was not a sanitation issue from the moisture. The Administrator stated she expected the pans to be cleaned or replaced. The Administrator stated the microwave and stove should have been cleaned daily and after each use. The Administrator stated the juice dispenser should have been cleaned daily. The Administrator stated she expected test strips to be within the correct date range. The Administrator stated hair restraints should be worn prior to going in the kitchen. The Administrator stated rounds were done once a week and if she noticed an issues staff were addressed immediately. The Administrator stated it was important to ensure compliance to prevent food borne illness and cross contamination. Record review of the facility's policy titled, Food Storage, revised 04/11/2022 indicated, .food will be handled in a safe and sanitary method to prevent contamination and food-borne illness .6. Food removed from its original packaging will be labeled with the following: a. receive date b. open date . Record review of the facility's policy titled, Food Service Uniforms, revised 04/2022 indicated, .all hair will be covered prior to entering the kitchen with a hairnet . A request for the facility policy regarding general kitchen sanitation was submitted to the Administrator on 05/23/204 at 5:00 p.m. A policy was not received prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 61 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the arbitration agreement was explained in a form and manner, including a language the resident or representative understood for 1 of 4 residents reviewed for arbitration agreements. (Resident #44) Residents Affected - Few The facility failed to ensure the binding arbitration agreement was fully understood and explained to Resident #44's responsible party, prior to signing it as part of the admission packet. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. The findings included: Record review of the face sheet, dated 05/22/2024, revealed Resident #44 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (brain disorder that causes memory loss, thinking problems and personality changes and gets worse over time), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), and bipolar disorder (serious mental illness characterized by extreme mood swings). The face sheet revealed Resident #44's family member was his Responsible Party and emergency contact. Record review of the significant change MDS assessment, dated 03/24/2024, revealed Resident #44 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #44 had an active diagnosis of Alzheimer's disease, schizophrenia, and bipolar disorder. Record review of the comprehensive care plan, revised on 02/28/2024, revealed Resident #44 had poor cognition and memory with a history of delusions. The care plan further revealed Resident #44 had difficulty conveying needs and understanding communication. Record review of the Resident and Facility Arbitration Agreement (page 16 of the admission Packet) revealed Resident #44's Responsible Party electronically signed the form on 02/21/2024 at 2:05 PM. The form further revealed the BOM also electronically signed the form as the community representative on 02/21/2024 at 2:14 PM. During an interview on 05/21/2024 beginning at 10:59 AM, the Responsible Party stated she was not aware that she had signed an arbitration agreement. The Responsible Party said when Resident #44 admitted to the facility she signed everything in the admission packet so quickly and the facility did not go over the admission packet with her. The Responsible Party said she would not have signed the arbitration agreement if she was aware, it was in the admission packet and the if facility staff would have explained to her what she was signing. During an interview on 05/24/2024 beginning at 11:58 AM, the BOM said the arbitration agreements were a part of the admission packet. The BOM stated the admission packet was either sent to the families electronically or completed at the facility. The BOM stated the responsibility of ensuring the admission packets were completed had been passed to several different facility staff members. The BOM stated the corporate office was completing them until she recently took back over. The BOM stated when the admission packets were completed at the facility, she went over every page individually with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 62 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the families. The BOM stated when the admission packet was completed electronically, the pages were only explained if the families had questions. The BOM stated the arbitration agreement was not required to have been signed as part of admitting to the facility. The BOM stated Resident #44's Responsible Party completed the admission packet electronically. The BOM stated the Responsible Party did not ask her any questions and so the arbitration agreement was not explained. The BOM said it was important to ensure the residents or responsible parties were aware of what paperwork they were signing. The BOM said if residents or responsible parties were not aware of what they were signing, they could have entered into legally binding agreements without their knowledge. During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated she expected the staff member completing the admission packet to explain the arbitration agreement to the resident or family. The Assistant Administrator stated the Administrator and nursing management were responsible for monitoring to ensure the residents and family were aware of what they were signing as part of the admission packet. The Assistant Administrator stated it was important to ensure the residents and families knew what they were signing before they signed so they could exercise their rights and make informed decisions. During an interview on 05/24/2024 at 1:14 PM, the BOM stated the facility did not have a policy related to arbitration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 63 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure coordination of care with Resident #13's hospice provider. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: Record review of a face sheet dated 5/23/2024 indicated Resident #13 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (memory loss/dementia), malnutrition, and high blood pressure. Record review of the consolidated physician's orders dated May 2024 indicated Resident #13 had an order to admit to hospice under his attending and his hospice physician dated 5/17/2024. Record review of the Quarterly MDS dated [DATE] indicated Resident #13 was usually understood and usually understands. The MDS indicated Resident #13's MDS indicated his BIMS was a 6 indicating he had severe cognitive impairment. The Quarterly MDS did not reflect the election of Resident #13's hospice benefit. Record review of the comprehensive care plan dated 5/23/2024 (after surveyor intervention) Resident #13 had a terminal diagnosis and was admitted to hospice services and was at increased risk for unavoidable skin issues, weight loss, and overall decline. The goal of the care plan was Resident #13 would have his comfort maintained. The interventions included to notify his hospice provider of any changes in condition, uncontrolled pain, or death. Another intervention was the facility would work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of the hospice Patient Information Report (obtained after surveyor intervention) indicated Resident #13 admitted to hospice services on 5/17/2024. The Patient Information Report indicated the certification period was from 5/17/2024 - 7/15/2024 for the primary diagnosis of malnutrition. Record Review of the Texas Medicaid Hospice Program Physician Certification of Terminal Illness form 3074 (after surveyor intervention) indicated Resident #13 elected hospice on 5/17/2024. Record review of the Hospice Certification and Plan of Care (obtained after surveyor intervention) indicated Resident #13 would have a skilled nurse visit 2 times weekly and then 2 as needed visits, the social worker visits were 1 time a month for one visit then 2 as needed visits, the home health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 64 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aide visits would be effective as of 5/19/2024 as 5 times a week, and the chaplain would visit 1 time a month for one visit then 2 as needed visits. The Hospice Plan of care indicated the hospice RN would evaluate Resident #13 and develop a nursing plan of care, the hospice nurse would monitor the Resident #13's pain level and report ineffective pain control to the physician. The Hospice Plan of Care indicated the medical social worker would evaluation social, emotional, and financial matters. The Chaplain would evaluate Resident #13 and develop a plan of care. The Hospice Plan of care indicated the hospice was not supplying any medical equipment. During an interview on 5/22/2024 at 3:00 p.m., the DON said Resident #13 admitted to hospice on last Friday 5/17/2024 and she unable locate the hospice binder in the facility and was unsure how to reach the hospice agency Resident #13 elected. The DON was unable to voice how often Resident #13 was seen by his hospice team, or the delineation of duties of each party. During an interview on 5/24/2024 at 9:25 a.m., the DON said Resident #13 was admitted on [DATE]. The DON said there was no coordination of care. The DON said the nursing staff should have asked the hospice provider for the documentation for the coordination of care. The DON said with no coordination of care there was a risk of continuity of care. The DON said the lack of continuity of care could cause increased emotional issues with the Resident #13 and his family. During an interview on 5/24/2024 at 9:39 a.m., the ADON said with the lack of the hospice coordination of care there could be a gap in the care and services provided to Resident #13. The ADON said the nurse, herself, and the DON were responsible for ensuring the coordination of care with the facility, Resident #13, and his hospice provider. The ADON said the gap in the care could cause a lack of services for Resident #13 and his family. During an interview on 5/24/2024 at 10:17 a.m., the Assistant Administrator said the DON was responsible for the coordination of care with the hospice providers. The Assistant Administrator said without the coordination of care the facility was unaware of the responsibilities of each party. The Assistant Administrator said the lack of awareness of responsibilities could cause the lack of the best care for Resident #13 and others. The Assistant Administrator said she was unaware of any monitoring system in place to ensure the continuity of care. The Assistant Administrator said the Administrator said the interviews with her was sufficient for him. Record review of a Hospice Program policy dated 2001 indicated hospice services were available to residents at the end of life. 1. Our facility has an agreement with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. 9. In general it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including a. determining the appropriate hospice plan of care .c. providing medical direction, nursing and clinical management of the terminal illness d. Providing spiritual, bereavement, and or psychosocial counseling and social services as needed; and e. providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 12. Our facility has designated the DON to coordinate care provided to the resident by our facility staff and the hospice staff. a. Collaborating with hospice representatives and other healthcare providers participating in the hospice care planning process for resident receiving there services; b. communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and the family; d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident; 2. Hospice election form; 3. Physician certification and recertification of the terminal illness specific to each resident; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 65 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 4 Names and contact information for hospice personnel involved in hospice car of each resident; 5. Instructions on how to access the hospice's 24-hour on-call system; 6. Hospice medication information specific to each resident; and 7. Hospice physician and attending physician orders specific to each resident. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain he resident's highest practicable physical, mental and psychosocial well-being. Event ID: Facility ID: 455900 If continuation sheet Page 66 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy (blocked or backward flow of uine). Residents Affected - Some Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS in section GG-Functional Abilities and Goals indicated Resident #44 was dependent of the staff to complete all of the effort of toileting. The MDS in section H-Bladder and Bowel H0100Resident #44 was indicated to have an indwelling catheter and in H0300 to have not rated due to the use of a Foley catheter. Record review of the Comprehensive Care Plan dated 3/06/2023 indicated Resident #44 an indwelling catheter 18 French with a 10 cubic centimeter bulb and was at risk for increased urinary tract infections. The goal of the care plan was Resident #44 would be free from catheter related trauma. The care plan interventions included to check Foley catheter placement, ensure Foley was secured via a Velcro strap to reduce friction/pulling. The care plan interventions also include the utilization of enhanced barrier precautions. Record review of the Consolidated Physician's orders dated May 2024 indicated Resident #44 had a Foley catheter 16 French with 10 cubic centimeters bulb related to obstructive uropathy. Record review of a urinalysis report dated 5/07/2024 indicated Resident #44 had an abnormal urinalysis with white blood cells resulted at 50 with a normal of none, bacteria resulted at few with a normal of none, blood and leukocytes results were moderate with the results should be negative. Record review of the Medication Administration Record dated 5/2024 indicated on 5/07/2024 Resident #44 was ordered Macrobid 100 milligrams one capsule two times daily for 7 days for a urinary tract infection. The Medication Administration Record also indicated on 5/10/2024 Resident #44 was ordered Levaquin 500 milligrams for 7 days for infection. During an observation and interview on 5/21/2024 at 11:31 a.m., the hospice aide and CNA Y prepared Resident #44 for incontinent care and Foley catheter care. The hospice aide applied her gloves, opened a small package of wipes and took out two wipes, then opened Resident #44's brief, then CNA Y rolled Resident #44 to his left side. The hospice nurse aide saw Resident #44 had a bowel movement. The hospice nurse removed her gloves, walked toward the bedside table when the responsible party handed her another package of wipes and some barrier cream. Then the hospice aide applied another pair of gloves and took the two wipes she previously removed and cleansed Resident #44's anal area. Then the hospice aide removed the dirty brief, opened the clean brief, and placed underneath Resident #44 then the hospice aide applied barrier cream to Resident #44's buttocks. CNA Y rolled Resident #44 onto his back, the hospice aide took two wipes and wiped off Resident #44's top of his penis only. The hospice aide closed Resident #44's brief, replaced the linens and then removed her gloves. The hospice aide failed to clean Resident #44's penis and foley catheter tubing during the Foley catheter care. The hospice aide failed to perform hand hygiene during the incontinent care, nor did she change gloves from dirty to clean. During the observation neither the hospice aide nor CNA Y donned (put on) PPE for enhanced barrier precautions even though the sign for enhanced barrier precautions was posted on Resident #44's closet, and PPE was in a wall hanging holder on his wall as you walked in his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 67 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some door. During the interview the hospice aide said she was unaware she should use enhanced barrier precautions by donning PPE during foley catheter care for Resident #44. During an interview CNA Y said he was aware of the enhanced barrier precautions but said he forgot to put on the PPE for enhanced barrier precautions. Record review of a Nursing Services-Competency Evaluation Skill/Procedure dated 4/26/2024 indicated the treatment nurse evaluated CNA Y skills for peri/incontinent care male without and with a catheter. The form indicated CNA Y met the skills. During an interview on 5/22/2024 at 7:03 a.m., CNA Y said the hospice aide failed to change her gloves between dirty and clean while performing incontinent care. CNA Y said the hospice nurse aide also failed to properly clean Resident #44's penis and catheter tubing with catheter care. CNA Y said it was important to change gloves between dirty and clean while performing incontinent care and Foley catheter care to prevent infections. CNA Y said he and the hospice aide should have used PPE for the enhanced barrier precautions. CNA Y said wearing the PPE prevents the spread of infections from one resident to another resident. During an interview on 5/22/2024 at 11:22 a.m., the hospice aide said she thought she performed incontinent care well. When the hospice aide was asked about changing the gloves between dirty and clean situations, she agreed she had not. When the hospice nurse aide was asked about performing catheter care and had she cleaned Resident #44's penis correctly and cleaned the tubing wiping away from Resident #44's penis opening she said she had not done so. The hospice CNA said she had been checked off on skills annually. The hospice CNA said when not performing incontinent care correctly Resident #44 could get a urinary tract infection. During an interview on 5/22/2024 at 4:55 p.m., the hospice DON said she expected the hospice aide to change her gloves between dirty and clean. The DON said she expected Foley catheter care to be performed correctly by cleaning the penis and the catheter tubing away from the opening of the penis. The DON said Resident #44 was at risk for infections when the Foley catheter care was not performed correctly. The DON said she was unaware if Resident #44 had a recent UTI. The DON said she was unaware of enhanced barrier precautions, and she had called the DON on 5/21/2024 after learning of this precaution from the hospice aide. During an interview on 5/24/2024 at 8:53 a.m., the DON said she expected the nurses to ensure Resident #13 and #44's catheters were secured properly. The DON said she expected this especially with these two residents as their Foley catheters were troublesome to replace requiring physician visits for replacement. The DON said stabilizing the Foley catheter prevents pulling and possible trauma from occurring. The DON said she expected the CNAs to perform incontinent care correctly. The DON said Resident #44 was at high risk for urinary tract infections and had even been septic (life-threatening infection) in the past. The DON said skills check off with the facility staff was annually, but she had not thought to ensure the contracted staff performed skills correctly. The DON said she had not thought to in-service the hospice providers on the enhanced barrier precautions newly initiated in April of this year. During an interview on 5/24/2024 at 9:57 a.m., the ADON said the catheter stabilizing device was a required device to prevent trauma from occurring to a resident. The ADON said the nurses were responsible for monitoring the placement of the securing device during their rounds. The ADON said she expected incontinent care to be performed currently and she would have expected CNA Y to stop the hospice CNA when he saw the hospice aide not performing incontinent care and Foley catheter correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 68 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The ADON said Resident #44 had been treated recently for a UTI and was at risk for UTIs with improper catheter care. During an interview on 5/24/2024 at 10:04 a.m., the Assistant Administrator said she expected a securing device to be applied for Foley catheters. The Assistant Administrator said when the device was not in place the Foley catheter could pull causing trauma. The Assistant Administrator said the nurses were responsible for ensuring the securing devices were properly placed. The Assistant Administrator said she expected incontinent care to be performed correctly to prevent UTIs. The Assistant Administrator said the ADON was responsible for training of the staff as the infection preventionist, and the DON was responsible for the oversight of the training and spot checking of staff skills. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #11 and Resident #44) and 1 of 3 dining rooms (men's secure unit dining room) reviewed for infection control. 1. The facility did not ensure Resident #11's urine specimen was adequately obtained to prevent potential contaminates in her urinalysis with culture and sensitivity. 2. The facility did not ensure Resident #11 was placed on isolation precautions when her culture and sensitivity showed multiple drug resistant organisms. 3. The facility failed to ensure Resident #44 was provided proper incontinent care and catheter care. 4. The facility failed to ensure MA F did not eat a donut while serving resident lunch trays in the men's secure unit dining room. These failures could place residents and staff at risk for cross contamination and the spread of infection. The findings included: 1. Record review of the face sheet, dated 05/24/2024, revealed Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizophrenia (serious mental disorder that affects how people interpret reality), multiple sclerosis (disease that affects the brain and spinal cord and causes nerve damage and communication problems), and parkinsonism (umbrella term for brain conditions that cause slowed movements, rigidity and tremors). Record review of the admission MDS assessment, dated 04/15/2024, revealed Resident #11 had clear speech and was understood by staff. The MDS revealed Resident #11 was able to understand others. The MDS revealed Resident #11 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #11 had no behaviors or refusal of care. The MDS revealed Resident #11 required partial/moderate assistant with toilet hygiene and toilet transfer. The MDS revealed Resident #11 was always incontinent of bladder. Record review of the comprehensive care plan, revised on 04/28/2024, revealed Resident #11 had episodes of incontinence which placed her at risk for infection. The interventions included: labs as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 69 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ordered by doctor, monitor for signs of infection, and notify doctor promptly. The care plan further revealed Resident #11 required limited assistant x 1 staff assistance with toileting. Record review of the culture and sensitivity results, received on 04/19/2024, revealed Resident #11 had 6 identified bacterial organisms in her urine. Three out of the six bacteria were less than 10,000 CFU /mL, which could have indicated contamination. The results also revealed Resident #11 had 4 antibiotic resistance markers, which included macrolide resistance, methicillin resistance, tetracycline resistance, and vancomycin resistance. Record review of the McGeer's Criteria for Infection, dated 04/20/2024, revealed Resident #11 had fluctuated mental status, and acute functional decline in locomotion. The assessment revealed Resident #11 did not meet the criteria for UTI without indwelling catheter. The assessment was blank regarding the physician notification of infection and his response for not meeting the criteria for antibiotic usage. During an interview on 05/22/2024 beginning at 5:17 PM, Resident #11 stated she had an infection when she first admitted to the facility. Resident #11 stated she was not sure if she was having symptoms, but they tested her urine. Resident #11 said she peed into a hat on the toilet. Resident #11 said she did not remember if staff helped her, but she was not cleaned prior to peeing in the hat. Resident #11 stated she has not had to stay in her room and staff had not put on PPE when helping her to the bathroom since she admitted to the facility. During an interview on 05/24/2024 beginning at 9:23 AM, CNA Y stated he has worked with Resident #11 since she admitted to the facility. CNA Y stated he did not believe Resident #11 had been on isolation precautions since admitted to the facility. CNA Y stated he was unsure if she had been treated for an infection. During an interview on 05/24/2024 beginning at 10:07 AM, the ADON stated she was the infection control preventionist. The ADON said Resident #11 was treated for a UTI close to when she admitted to the facility. The ADON stated Resident #11 had not been placed on isolation precautions since she admitted to the facility. The ADON reviewed Resident #11's culture and sensitivity results and stated she was unaware Resident #11 had antibiotic resistance organisms in her urine. The ADON stated multiple organisms in the urine could have indicated the specimen was contaminated and she was not sure if another specimen was re-collected. The ADON stated she was the nurse who collected the urine specimen. The ADON stated she placed a hat in Resident #11's toilet but she did not provide education to Resident #11 on obtaining a clean-catch urine specimen. The ADON stated Resident #11 toileted herself, so she was unsure if Resident #11 cleaned herself prior to peeing in the hat. The ADON stated when the culture and sensitivity results were potentially contaminated and showed antibiotic resistant organisms, Resident #11 should have been placed on contact isolation precautions and the specimen should have been re-collected. The ADON stated this did not happen for Resident #11. The ADON said it was important to ensure urinalysis with culture and sensitivities were reviewed for potential contamination and antibiotic resistance organisms to prevent the spread of infection to others and so the residents would have been treated appropriately. During an interview on 05/24/2024 beginning at 11:14 AM, the DON stated the ADON was responsible for reviewing the urinalysis with culture and sensitivities. The DON said the charge nurse should have obtained the cultures and notified the doctor, then the ADON should have reviewed the cultures. The DON reviewed Resident #11's labs. The DON stated Resident #11 should have been placed on contact isolation precautions pending a repeat UA. The DON stated the repeat UA should have been obtained via (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 70 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Level of Harm - Minimal harm or potential for actual harm in and out catheter. The DON stated a hat was not considered sterile and the multiple organisms could have been a contaminated urine specimen. The DON stated it was important to ensure urine specimens were obtained properly and isolation precautions were implemented for antibiotic resistant organisms to prevent cross contamination and untreated UTIs, which could have led to sepsis or super-infections caused by the facility not providing good care. Residents Affected - Some During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated the ADON was responsible for monitoring labs to include UAs and following up with nursing staff as needed. The Assistant Administrator stated she expected proper infection control measure to have been implemented for a resident with antibiotic resistant organisms and potentially contaminated urine results. The Assistant Administrator stated it was important to follow the proper infection control procedures to prevent the spread of infection. 3. During an observation on 05/22/2024 at 12:38 p.m., MA F was observed eating a donut while serving residents their lunch trays on the men's secure unit. During an interview on 05/22/2024 at 1:53 p.m., MA F stated she forgot she had the donut in her hand because she was hypoglycemic (low blood sugar). MA F stated it was important not to eat when passing out lunch trays because it was not appropriate. MA F stated the failure was cross contamination. During an interview on 05/23/2024 at 11:00 a.m., LVN U stated the charge nurses were responsible for ensuring the CNAs were not eating while passing out resident lunch trays. LVN U stated when she noticed MA F with the donut in her hand and told her to put it down. LVN U stated it was important not to eat when passing out trays because it could make the residents feel bad, they are not eating the same thing and it was not appropriate. LVN U stated the failure was cross contamination. During an interview on 05/24/2024 at 8:20 a.m., the DON stated she did not expect the CNAs to be eating on the unit period. The DON stated it was important not to be eating when passing out trays because it was a dignity issue. The DON stated the failure was infection control or possible resident staff altercation being on the secure unit. The DON stated she would monitor by making rounds during meals. During an interview on 05/24/2024 at 9:18 a.m., the ADON stated she did not expect the CNAs to be eating on the unit. The ADON stated it was important for the staff to not be eating because of cross contamination and infection control. The ADON stated she would monitor by in service, education, and reiterate that eating while serving residents was not acceptable. During an interview on 05/24/2024 at 9:52 a.m., the Administrator stated staff eating on the secure was not acceptable. The Administrator said the DON was responsible for providing oversight for the CNAs. The Administrator said it was important for the staff not to eat when serving trays for cross contamination. The Administrator stated the failure was infection control. The Administrator stated she would monitor by rounds and reenforcing staff was not to be eating when serving the residents. Record review of a Catheters-Insertion and Care: Indwelling, Straight, Supra-Pubic, and External dated 4/2021 indicated the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications Record review of a Perineal Care policy dated 10/01/2021 indicated the policy was to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 71 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition Steps in the Procedure .2. Wash and dry your hands thoroughly 6. put on gloves .9. Use wipe and apply skin cleansing agent. B. Wash perineal area starting with the urethra and working outward. (Note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches.) 1. Retract foreskin of the uncircumcised male. 2. Cleanse the urethral area using a circular motion. 3. Continue to wash the perineal area including the penis, scrotum, and inner thighs. Do not reuse the same side of the disposable wipe, change the surface position of the disposable wipe and/or obtain a clean wipe to clean the urethra. C. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter 11. Remove gloves and discard in designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable 15. Wash and dry your hands thoroughly. Record review of a Hand Hygiene policy dated 8/04/2021 indicated hand hygiene is used to prevent the spread of pathogens in healthcare setting. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub to destroy harmful pathogens, such as bacteria or viruses on the hands. Record review of the facility's policy titled Infection Control revised on 01/05/2022, indicated maintain a safe, sanitary, and comfortable environment for personnel, resident's, visitors, and the public FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 72 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a infection prevention and control program that includes antibiotic use protocol and a system to monitor antibiotic use for 1 of 4 residents and reviewed for antibiotic stewardship program. (Resident #11) Residents Affected - Some The facility did not ensure Resident #11 was assessed using the established and accepted criteria to determine if her UTI met the criteria for antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of the face sheet, dated 05/24/2024, revealed Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizophrenia (serious mental disorder that affects how people interpret reality), multiple sclerosis (disease that affects the brain and spinal cord and causes nerve damage and communication problems), and parkinsonism (umbrella term for brain conditions that cause slowed movements, rigidity and tremors). Record review of the admission MDS assessment, dated 04/15/2024, revealed Resident #11 had clear speech and was understood by staff. The MDS revealed Resident #11 was able to understand others. The MDS revealed Resident #11 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS revealed Resident #11 had no behaviors or refusal of care. The MDS revealed Resident #11 required partial/moderate assistant with toilet hygiene and toilet transfer. The MDS revealed Resident #11 was always incontinent of bladder. Record review of the comprehensive care plan, revised on 04/28/2024, revealed Resident #11 had episodes of incontinence which placed her at risk for infection. The interventions included: labs as ordered by doctor, monitor for signs of infection, and notify doctor promptly. The care plan further revealed Resident #11 required limited assistant x 1 staff assistance with toileting. Record review of the culture and sensitivity results , received on 04/19/2024, revealed Resident #11 had 6 identified bacterial organisms in her urine. Three out of the six bacteria were less than 10,000 CFU /mL, which could have indicated contamination . Record review of the McGeer's Criteria for Infection, dated 04/20/2024, revealed Resident #11 had fluctuated mental status, and acute functional decline in locomotion. The assessment revealed Resident #11 did not meet the criteria for UTI without indwelling catheter. The assessment was blank regarding the physician notification of infection and his response for not meeting the criteria for antibiotic usage . During an interview on 05/22/2024 beginning at 5:17 PM, Resident #11 stated she had an infection when she first admitted to the facility. Resident #11 stated she was not sure if she was having symptoms, but they tested her urine. Resident #11 said she peed into a hat on the toilet. Resident #11 said she did not remember if staff helped her, but she was not cleaned prior to peeing in the hat. During an interview on 05/24/2024 beginning at 10:07 AM, the ADON stated she was the infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 73 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some control preventionist. The ADON said Resident #11 was treated for a UTI close to when she admitted to the facility. The ADON stated multiple organisms in the urine could have indicated the specimen was contaminated and she was not sure if another specimen was re-collected . The ADON stated she was the nurse who collected the urine specimen. The ADON stated she placed a hat in Resident #11's toilet but she did not provide education to Resident #11 on obtaining a clean-catch urine specimen. The ADON stated Resident #11 toileted herself, so she was unsure if Resident #11 cleaned herself prior to peeing in the hat. The ADON stated when the culture and sensitivity results were potentially contaminated and showed antibiotic resistant organisms, Resident #11 should have been placed on contact isolation precautions and the specimen should have been re-collected. The ADON stated this did not happen for Resident #11. The ADON stated she believed Resident #11 did meet the criteria for infection it just was not documented by the facility nurses. The ADON stated Resident #11 was having urgency and odor to her urine. The ADON stated she believed the nurses had a lack of education for the McGeer's criteria and additional training was needed . The ADON stated a progress note should have been placed in the computer if Resident #11 did not meet the criteria for antibiotics that revealed the doctor was notified and his response. The ADON said it was important to ensure urinalysis with culture and sensitivities were reviewed for potential contamination and antibiotic resistance organisms to prevent the spread of infection to others and so the residents would have been treated appropriately. During an interview on 05/24/2024 beginning at 11:14 AM, the DON stated the ADON was responsible for reviewing the urinalysis with culture and sensitivities. The DON said the charge nurse should have obtained the cultures and notified the doctor, then the ADON should have reviewed the cultures. The DON reviewed Resident #11's labs. The DON stated a hat was not considered sterile and the multiple organisms could have been a contaminated urine specimen. The DON said the doctor should have been notified if Resident #11 did not meet the criteria for antibiotic use. The DON stated it was important to ensure urine specimens were obtained properly and antibiotic stewardship polices were implemented to prevent cross contamination and antibiotic resistance related to unnecessary antibiotics . During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated the ADON was responsible for monitoring labs to include UAs and following up with nursing staff and doctor as needed. The Assistant Administrator stated she expected proper infection control measure to have been implemented for a resident with antibiotic resistant organisms and potentially contaminated urine results. The Assistant Administrator stated it was important to follow the proper infection control procedures to prevent the spread of infection. Record review of the Antibiotic Stewardship Program, revised 10/01/2021, revealed .infection preventionist .monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections . and .the community uses an evidence-based approach to antibiotic protocols for recommendations to licensed independent practitioners . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 74 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for 1 of 3 units (the facility's main building to include the dining room, hallway, and room [ROOM NUMBER], 49, and 52). Residents Affected - Some The facility did not maintain an effective pest control program to ensure the facility was free of flies in the main building dining room, hallway, and Resident Room's 48, 49, and 52. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the pest control log dated 10/10/2022, 03/02/2023, 06/07/2023, 09/06/2023, 10/05/2023, 11/01/2023, 12/09/2023, 01/03/2024, 01/30/2024, 02/07/2024, and 03/05/2024 revealed the pest control company had serviced the facility on the above dates . The log did not specify the areas that were serviced. Record review of the service notification from the pest control company , dated 05/01/2024, revealed Upon arrival I met with Director of Plant Operations, He said no issues since last visit. I explained plan of service to him and started with servicing .I visited with kitchen staff saying no issues at this time .I serviced fly light. I treated all common areas and exits with a liquid residual to help with occasional invading pest . The pest control company did not implement additional measures to prevent or help reduce flies as it was not reported by the facility. During an observation and attempted interview on 05/20/2024 at 9:45 AM in room [ROOM NUMBER], a fly was buzzing around the room and landed on Resident #31''s left leg. Resident #31 was unable to effectively communicate as evidenced by confused conversation. During an observation on 05/20/2024 at 9:55 AM, multiple flies were buzzing around in the hallway near room [ROOM NUMBER] and 51. During an observation and interview on 05/20/2024 at 10:02 AM in room [ROOM NUMBER], a fly was buzzing around the room and landed on Resident #53's gray hoodie. Resident #53 said the flies were annoying. During an observation 05/20/2024 at 10:08 AM, multiple flies were flying around the hallway in the main building. During an observation on 05/20/2024 at 10:15 AM in room [ROOM NUMBER], a fly was sitting on a bed side table. During a dining observation on 05/20/2024 beginning at 12:30 PM, multiple flies (approximately 6 - 7) were landing on the tables in the dining room while trays were being served. Resident #6 was swatting flies aware from her food. During a dining observation on 05/20/2024 at 12:39 PM, Resident #6 had a fly on her food. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 75 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0925 #6 was unable to communicate as evidenced by confused conversation. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 05/20/2024 beginning at 3:16 PM, Resident #215 was sitting at the dining room table eating his lunch meal. Resident #215 stated he just returned from an appointment. There were multiple flies landing on the table around his food. Resident #215 stated he had noticed the flies but did not think anything about them. Residents Affected - Some During an observation on 05/21/2024 at 9:21 AM, Resident #215 was sitting alone at the dining room table with his breakfast tray in front of him. There was a fly sitting on the left side of the table, near his breakfast tray. During an observation on 05/21/2024 at 9:29 AM, Resident #215 continued to eat from his breakfast tray at the dining room table. Approximately 5 - 6 flies were flying around and landing on the table near his food. During an interview on 05/24/2024 beginning at 9:23 AM, CNA Y stated some of the residents had complained about the flies buzzing around the facility. CNA Y said the facility staff propped the smoking door open when taking the residents outside to smoke. CNA Y said he had asked the staff members to stop propping the door open especially with meal service. CNA Y stated he had also mentioned it to the Director of Plant Operations and was told the pest control company had been out to exterminate. CNA Y stated it was important to ensure measures were taken to keep flies out of the facility because the facility was the resident's home. CNA Y said when flies land on stuff they carry disease and infections. CNA Y stated it was important to maintain a clean and sanitary environment. During an interview on 05/24/2024 beginning at 11:33 PM, RN B stated the issues with flies only occurred during the summer time because the smokers keep the doors propped open. RN B stated residents had complained about the flies and the door being kept propped open. RN B said they had to prop the doors open to get the residents outside timely. RN B said all management staff were aware of the ongoing issues with the flies. RN B said she was unsure if any pest control measures or treatments were being conducted. RN B said she had educated staff who take the residents out to smoke to ensure they were not keeping them propped open. RN B stated it was important to ensure measure were taken to prevent and reduce flies in the facility because flies spread bacteria and feces. RN B stated flies were unpleasant and unsanitary and she would not have wanted them in her own home. During an interview on 05/24/2024 beginning at 11:54 AM, Housekeeper EE stated the flies had been getting worse because the facility staff were leaving the doors cracked. Housekeeper EE stated no residents had complained to her about the flies. Housekeeper EE said she had reported the flies to the management staff, and they stated the bug man was supposed to come. Housekeeper EE said she had not noticed the flies getting better. Housekeeper EE said it was important to ensure measures were taken to prevent the flies from entering the facility, so the flies did not land in the resident's food or make maggots. During an interview on 05/24/2024 beginning at 12:08 PM, the Director of Plant Operations stated he had noticed the flies in the facility. The Director of Plant Operations said the door fan had been out for approximately one month and he was trying to get it operational. The Director of Plant Operations stated the flies have gotten worse since it was getting warmer outside. The Director of Plant Operations stated the pest control company came to the facility at the beginning of every month and was scheduled to come out soon. The Director of Plant Operations stated he had not made any extra calls to the pest control company when the flies were noticed. The Director of Plant Operations said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 76 of 77 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 455900 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Mount Pleasant 1606 Memorial Ave Mount Pleasant, TX 75455 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no residents or staff members had complained about the flies in the facility. The Director of Plant Operations stated it was important to ensure measures were taken to prevent and control flies from entering the facility to maintain sanitary conditions. During an interview on 05/24/2024 beginning at 12:22 PM, the Assistant Administrator stated she was aware of problems with flies. The Assistant Administrator stated the pest control company regularly came to the facility once per month. The Assistant Administrator said the Director of Plant Operations was getting a new blower. The Assistant Administrator said the pest control company could have come to the facility in between visits and they had not been in, but she would be calling them today. The Assistant Administrator stated the Director of Plant Operations was responsible for ensure the pest control program was maintained. The Assistant Administrator stated she was responsible for overseeing the Director of Plant Operations. The Assistant Administrator stated it was important to ensure appropriate measures were put in place to prevent or reduce the occurrence of flies for infection control and sanitation. The Assistant Administrator stated she would not have wanted the flies in her own home. Record review of the Pest Control policy, effective 02/01/2017, revealed 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . and 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455900 If continuation sheet Page 77 of 77