Health inspection·May 13, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and social services. The ADM stated it was her expectation that all advance directives were completed accurately. The ADM stated she was not aware Resident #40's advance directive was not completed properly. The ADM stated the DON was responsible for ensuring all advance directives were filled out correctly. The ADM stated the advance directive was also reviewed during the resident's care plan meetings. The ADM stated Resident #40's advance directive must have been overlooked, and it would be corrected as soon as possible. The ADM stated if a resident's advance directive was not filled out accurately, the resident's wishes may not be honored. During an interview on 05/13/2025 at 11:15 AM the DON stated she was responsible for reviewing residents' advance directives to ensure they were completed properly. The DON stated she was not aware Resident #40's advance directive was not completed accurately. The DON verified Resident #40's advance directive was not completed correctly and stated it was overlooked. The DON stated she completed the advance directive for Resident #40, and she did not realize it was not accurate. The DON stated she would ensure the advance directive was updated as soon as possible. The DON stated it was her expectation that all advance directives were completed correctly to ensure the resident's wishes were followed. The DON stated if a resident's advance directive was not completed properly or fully, the resident was at risk of not having their wishes followed. Record review of the facility policy, Advance Directive, Effective 4/2020, revealed the following documentation: PROCEUDRE: 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 2 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 16 of 21 confidential residents. The facility failed to ensure 16 of 21 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, access to Grievance forms, information regarding who the facility Grievance officer was with their contact information, and accommodations to file an anonymous Grievance. This failure could place the residents at risk of unresolved Grievances and decreased quality of life. Findings include: During a confidential interview on 05/12/2025 at 10:00 AM with the resident council, 16 confidential residents stated they did not know how to file a formal Grievance. Residents attending Resident Council stated they did not have access to Grievance forms, and they did not know where Grievance forms were kept. Additionally, residents in Resident Council were not aware of who their Grievance Officer was, nor the process to resolve Grievances. They stated they had never seen a posting in the facility pertaining to Grievances. Residents in Resident Council stated they did not know how to file anonymous Grievances, and they were not aware they had the option to file a formal complaint anonymously. 14 of the 16 residents in attendance had been residing at the facility for 6 months or longer. Observation of prominent postings on 05/12/2025 at 11:00 AM; the facility did not have instructions regarding the Grievance procedure with any of their prominent postings. Grievance forms were not readily available to residents in the facility, and there were no accommodations to submit a Grievance anonymously. During an interview on 05/13/2025 at 10:45 AM the ADM stated she was the Grievance Officer for the facility, and she was responsible for ensuring Grievances were resolved. The ADM stated all grievances were recorded by facility staff, and blank grievance forms were kept in the administrator's office or at the nurse's station. The ADM stated the blank grievance forms were not accessible to residents without requesting the form from a facility staff. The ADM stated Grievances were given to each department head to ensure resolution and the ADM followed up to ensure Grievances were resolved as soon as possible. The ADM stated residents were informed of their right to file a Grievance upon admission, during safe surveys, and during resident council meetings. The ADM stated, although there was no procedure in place currently that allowed residents to obtain a Grievance form on their own or to file it anonymously, she would set up a Grievance box and have the forms accessible immediately. The ADM stated if a resident was unable to file a Grievance and/or wanted to file anonymous Grievances and they were unable to, the resident could've been at risk of psychosocial harm, as it could have been upsetting to the resident if their complaints were not addressed. During an interview on 05/13/2025 at 11:15 AM the DON stated the ADM was the facility's Grievance coordinator, but any staff could have filled out a Grievance form for a resident. The DON stated Grievance forms were filled out by facility staff, and there was no location for residents to obtain Grievance forms on their own. The DON stated if a resident wanted to file an anonymous Grievance, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 3 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would have filled the form out for them and left the resident's name off of it. The DON stated there was not a way for a resident to obtain a Grievance form without requesting one from a facility staff. The DON stated residents were advised of their right to file Grievances upon admission and during Resident Council meetings. The DON stated there was not a posting with instructions on filing Grievances in the facility, but it was communicated verbally by staff to residents. The DON stated Grievances were resolved by each Department head, and the ADM followed up to ensure they were able to address complaints timely. The DON stated, if a resident was unable to file a Grievance or of the resident wanted to file an anonymous Grievance, and they were unable to, this could have placed the resident at risk of psychosocial harm. The DON stated the resident could have feared retaliation or might not express their concerns if they were unable to file anonymous Grievances. The DON stated if a resident could not file a Grievance, the resident's concerns may have gone unheard and unresolved. Record review of the facility policy, Grievance (Section: Administration, Department: Administration), Effective 04/01/2017, revealed the following documentation: POLICY: Our facility will assist residents, their representatives, other interested family members or resident advocates in filing grievances or complaints when such requests are made. The facility will make prompt efforts to resolve all grievances. PROCEDURE 1. Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted on the resident bulletin board. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 4 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #36) reviewed for supervision, 1. The facility failed to provide effective monitoring and interventions to reduce Resident #36's wandering which was intrusive to other residents' privacy and unsafe for Resident #36 and other residents 2. The facility failed to keep the administrative offices closed and not accessible to the residents when no staff were present. These failures could place residents at risk for injury and not receiving adequate supervision in order to reduce the risk of accidents and meet plan goals. The findings include: Record review of Resident #36's admission record, dated 05/12/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (memory loss and decline in other mental abilities), cognitive communication deficit (struggles to communicate), and wandering. Record review of Resident #36's comprehensive MDS assessment, dated 04/11/25, the staff assessment for mental status revealed Resident #36 had short-term memory problems and long-term memory problems and Resident #36's cognitive skills for daily decision making was severely impaired - never/rarely made decisions. The MDS further revealed Resident #36 exhibited wandering 4 to 6 days, but less than daily. Record review of Resident #36's comprehensive care plan, undated, revealed a Focus area, Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and diagnosis of dementia. Wears wanderguard Goal: Resident's safety will be maintained throughout the review date and Interventions: .4. Provide structured activities: toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes. With an initiation date of 04/02/25. On 05/11/25 at 1:55 PM, a confidential interview was conducted with a resident and the resident stated another female resident walks the halls and got into her room and tried to unplug the TV. The resident stated the female resident just walks and was not aggressive. Observation on 05/12/25 at 8:53 AM, Resident #36 was observed to be sitting at the foot of the bed for Resident #24. Resident #24 was observed with his eyes closed and was facing towards the wall. Resident #36 was touching and moving the blanket at the foot of the bed. Observation on 05/12/25 at 9:56 AM, Resident #36 was observed wandering into the Resident Council meeting in the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 5 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/12/25 at 10:04 AM, Resident #36 was observed walking up to another resident in the dining room and standing right in front of her in her personal space. Surveyor was required to ask for staff assistance during the Resident Council Meeting. Observation on 05/12/25 at 10:08 AM, the AD walked Resident #36 out of the Resident Council meeting and took her to her room. Observation on 05/12/25 at 11:30 AM, Resident #36 was observed wandering towards the front windows in the lobby and the wanderguard alarm began alarming. Observed a CNA assist Resident #36 away from the front lobby door. Observation on 05/12/25 at 1:57 PM, Resident #36 was observed wandering down the 200-hallway where administrative offices are located. Resident #36 was observed walking into the administrator's office and no staff was observed in the administrator's office. Observation on 05/12/25 at 2:02 PM, Resident #36 was observed wandering into Resident #24's room and walked to his personal fridge. Observation on 05/12/25 at 2:03 PM, LVN A was observed redirecting Resident #36 out of Resident #24's room. Observation on 05/12/25 at 2:43 PM, Resident #36 was observed wandering down the 100-hallway yelling out randomly. Interview on 05/12/25 at 2:52 PM, LVN B stated she was aware of the wandering behavior for Resident #36. LVN B stated the residents did complain when Resident #36 was first admitted to the facility about her going into other resident's rooms. LVN B stated she will shut some resident's doors or will place stop signs outside their door to help Resident #36 not go into the other resident's rooms. LVN B stated the staff will try to keep Resident #36 with them to keep her busy, but she is on her own when staff get busy with other things. LVN B stated she has seen Resident #36 fall asleep on an empty bed in another resident's room before. LVN B stated she has been trained on how to redirect the resident by offering snacks or changing their direction. LVN B stated most of the residents are used to Resident #36 by now. LVN B stated a potential negative outcome to the residents with Resident #36 wandering into their room was it could get physical and someone could get hurt. Interview on 05/12/25 at 3:07 PM, the DON stated she was aware of Resident #36's wandering. The DON stated they have been working with psychiatric services for the behavior and stated her medications have been adjusted over a couple of weeks. The DON stated some of the residents are aggravated with Resident #36's wandering into their rooms, but she believed Resident #36 wandered into other rooms less often at this time. The DON stated most residents will redirect Resident #36 themselves and some residents use the stop signs at their doors. The DON stated the stop signs help prevent Resident #36 from going into those rooms, but she has seen Resident #36 go into some resident rooms and she will put her hands on their items. The DON stated the colorful items and stuffed animals are the items Resident #36 will pick up. The DON stated Resident #36 had even gone in her office at one time when it was left open and had drunk most of her diet coke one time. The DON stated Resident #36 required a lot of redirections from staff. The DON stated a potential negative outcome for the residents was Resident #36 could hurt another resident or another resident could hurt Resident #36 if she wandered into their room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 6 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/13/25 at 10:10 AM, the ADM stated she expected staff to maintain a safe environment for her and other residents at all times. The ADM stated she tries to shut her office when she leaves but forgets at times. The ADM stated staff kept items in their offices that could harm a resident if left unsupervised. The ADM stated she was not aware of any other resident's complaining of Resident #36 wandering into their room and stated the facility can order stop signs to help prevent the wandering into other resident's rooms. The ADM stated Resident #36 was easily redirected and staff had been trained on how to redirect residents. The ADM stated a potential negative outcome to Resident #36 was she could agitate other residents or she could get into something she shouldn't with the administrative offices not being shut when not in use. Interview on 05/13/25 at 11:35 AM, the DON stated the facility did not have a specific policy for wandering behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 7 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 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** Based on observation, interview, and record review, the facility failed to establish and 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 1 of 6 residents (Residents #39) reviewed for infection control. Residents Affected - Few 1. CNA A failed to change her gloves and utilize hand hygiene during incontinence care with Resident #39. These failures could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #39's undated face sheet revealed a [AGE] year-old female originally admitted to the facility 11/5/2024. Resident #39 had a medical history of hypertension (high blood pressure), depression, and cerebral infarction (a condition where brain tissue dies due to a lack of blood flow, causing necrosis in the brain). Record review of Resident #39 of annual MDS dated [DATE] Section H- Bladder and bowel revealed Resident #39 was frequently incontinent of bowel and bladder. During an observation on 5/12/2025 at 10:01 AM, CNA A donned clean gloves, removed Resident #39's brief and cleaned the peri area. CNA A assisted resident to turn onto her right side and cleaned Resident #39's buttocks. CNA A removed the dirty brief and grabbed a clean brief. CNA A placed the clean brief onto Resident #39 and removed dirty gloves. CNA A failed to change her gloves and utilize hand hygiene during incontinence care. During an interview with the DON on 5/13/2025 at 10:56AM, she stated staff are trained on infection control annually. She stated hand hygiene training and PPE is done quarterly. She stated the ADON and the DON are responsible for training staff. She stated her expectation of staff is to change their gloves during incontinence care and use hand sanitizer in between glove changes or if they are visibly soiled, she expects them to wash their hands with soap and water. She stated the potential negative outcome could be a UTI or contamination. She stated CNA A would be getting re-trained on incontinence care. She stated surveillance is monitored by routine check offs and monitoring for infection trends. During an interview with the ADM on 5/13/2025 at 11:15AM she stated the ADON and ADM are the infection control preventionist. She stated training on infection control and hand hygiene is done upon hire, annually and as needed. She stated her expectation of staff is for them to utilize hand hygiene between glove changes and to change their gloves during incontinence care. She stated the potential negative outcome could be spreading infection to the residents or to the staff. She stated she was not aware CNA A had not been changing her gloves and using hand hygiene during incontinence care but there would be more training. During an interview with CNA A on 5/13/2025 at 11:35AM, she stated when she was hired about a month (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 8 of 9 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 455936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Lamesa 1201 N 15th St Lamesa, TX 79331 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 - Few ago, she was not trained on infection control. She stated she did not know who the infection preventionist was. She stated she had been trained on infection control and hand hygiene during her career. She stated she was not aware of having to change her gloves during incontinence care. She stated she does change her gloves when providing incontinence care for a bowel movement. She stated the potential negative outcome of not changing your gloves and using hand sanitizer could be spreading infection and being unsanitary. She stated she is now aware of having to change her gloves during incontinence care. Record review of facility policy titled Hand Hygiene last revised 10/24/2022 revealed: Hand hygiene is used to prevent the spread of pathogens in healthcare settings. 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. .1. You should always perform hand hygiene: Before applying and after removing personal protective equipment (e.g. gloves, gown, mask, face shield .) Record review of blank facility document titled Nursing Services- Competency Evaluation, dated 6/13 revealed; .remove soiled clothing or brief. Place soiled brief/clothing in plastic bag .remove gloves, clean hands (may use gel) apply new gloves .clean starting at waist band place soiled items in plastic bag .remove gloves, place soiled items in plastic bag. Clean hands (may use gel) and apply clean gloves .position clean brief under resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455936 If continuation sheet Page 9 of 9