Health inspection·November 2, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm During an observation on 10/30/2023 beginning at 10:27 AM, CNA B returned to Resident #25's room. CNA B did not knock or introduce herself. CNA B placed his water pitcher with ice water on his bedside table, then went into his bathroom and wet a washcloth with water. CNA B walked over to Resident #25 and then started wiping his face. CNA B then placed lotion on his head and face. CNA B did not explain to Resident #25 what she was doing. Residents Affected - Few During an interview on 10/30/2023 beginning at 11:00 AM, CNA B stated she should have knocked prior to entering Resident #25's room. CNA B stated, I wasn't paying attention. CNA B stated it was important to knock prior to entering so the resident would know she was coming in. During an interview on 11/01/2023 beginning at 11:03 AM, Resident #25 stated staff normally knocked on his door and started talking. Resident #25 stated he was able to identify the staff by their voice. Resident #25 stated he knew a staff member was in his room because he heard them moving around. During an interview on 11/01/2023 beginning at 2:13 PM, CNA B stated she should have introduced herself and explained what she was doing while in Resident #25's room. CNA B stated she normally knocked, introduced herself, and explained the procedure but she was busy and probably just did not think about it. CNA B stated it was important to knock, introduce yourself, and explain the procedure to a visually impaired resident to ensure they did not become scared and knew she was in the room. CNA B stated it was important to maintain respect and dignity. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated she expected staff to knock, explain, and interact with residents while providing care. The DON stated it was monitored by random observations during morning rounds. The DON stated it was important to ensure staff knocked, explained, and interacted with residents while providing care to maintain respect of the resident and prevent an invasion of privacy. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she expected staff to ensure they knocked prior to entering a resident's room and explained what they were doing while providing care. The Administrator stated she was responsible for monitoring to ensure staff knocked, introduced themselves and explained the procedure to residents. The Administrator stated it was important to ensure staff knocked, introduced themselves, and explained the procedure to the residents to maintain their privacy. 2. During an observation on 10/30/2023 at 10:54 a.m., CNA B entered Resident #159 room without knocking. During an interview on 10/30/2023 at 10:57 a.m., Resident #159 stated usually the staff knocked prior to entering. During an interview on 10/30/2023 at 11:00 a.m., CNA B stated she should have knocked prior to entering Resident #159 room. CNA B stated, I wasn't paying attention. CNA B stated it was important to knock prior to entering so the resident would know she was coming in. During an interview on 11/02/2023 at 9:11 a.m., the DON stated she expected staff to knock prior to entering rooms. The DON stated the department heads which included the Administration, Activity Director, Social Worker, ADON, BOM, MDS Coordinator and herself were responsible for making partner rounds. The DON stated during resident council there was a complaint by a resident that staff was not knocking on doors prior to entering. The DON stated an in-service was done and since then there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 2 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no further complaints, that she was aware of. The DON stated it was important to knock prior to entering for the resident's privacy and residents right. The DON stated the risk associated with not knocking prior to enring was the resident's privacy had been invaded. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she expected staff to knock prior to entering resident's room. The Administrator stated she monitored by doing random hall rounds and in servicing staff when an issue was noted. The Administrator stated she had not noticed any issues related to not knocking prior to entering. The Administrator stated it was important to knocked prior to entering to protect the resident's privacy. Record review of the facility's policy titled Quality of Life-Dignity revised on 08/2009, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . 1. Residents shall be treated with dignity and respect at all times . 6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents' rooms 8. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 3 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 residents (Resident #10) reviewed for reasonable accommodation of needs. Residents Affected - Few The facility did not ensure Resident #10's call light was within reach. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 11/01/23, revealed Resident #10 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, heart failure (progressive heart disease that affects pumping action of the heart muscles), cerebrovascular disease (umbrella term for conditions that impact the blood vessels in your brain), and chronic kidney disease, stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant; Kidney disease often cannot be cured in Stage 3, and damage to your kidneys normally is not reversible). Record review of the quarterly MDS assessment, dated 07/27/23, revealed Resident #10 had clear speech and was usually understood by staff. The MDS revealed Resident #10 was usually able to understand others. The MDS assessment revealed Resident #10 had a BIMS of 11, which indicated moderately impaired cognition. The MDS assessment revealed Resident #10 had no behaviors or refusal of care. Record review of the comprehensive care plan, revised on 07/15/23, revealed Resident #10 was at risk for falls and fractures related to cognitive impairment. The interventions included: ensure call light is in reach and answer promptly. During an observation on 10/30/23 beginning at 9:36 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. During an observation on 10/31/23 beginning at 9:33 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. During an observation and interview on 11/01/23 beginning at 10:52 AM, Resident #10 was sitting up on the side of her bed. Resident #10's call light was curled up on the ground, out of arms reach, near the dresser that was located beside her bed. Resident #10 stated she did not normally use her call light. Resident #10 stated her roommate called for her or she would catch staff as they entered her room to get what she needed. During an interview on 11/01/23 beginning at 4:30 PM, CNA B stated she was responsible for ensuring call lights were within reach for the residents. CNA B stated Resident #10 did not use her call light frequently and was pretty independent. CNA B stated she did not think about making sure her call light was in reach. CNA B stated it was important to ensure call lights were left in reach for the residents in case they needed anything or any help. CNA B stated call lights were important if there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 4 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0558 was an emergency. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to ensure call light were left within reach. The DON stated call light placement was monitored during rounds. The DON stated call light placement was important to ensure residents were able to call for help or ask for assistance. Residents Affected - Few During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected staff to ensure every resident had a call light that was within reach. The Administrator stated everyone was responsible for ensuring call lights were left in reach. The Administrator stated it was important to ensure call lights were left within reach, so they were able to call for assistance, if it was needed. Record review of the Quality of Life - Accommodation of Needs policy, revised August 2009, did not address call light placement or use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 5 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some 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 right to formulate an advanced directive was provided for 3 of 20 residents (Residents #4, #16 and #24) reviewed for advanced directives. 1. The facility did not ensure Resident #4's OOH-DNR included the physician signature and physician date the document was signed. 2. The facility did not ensure Resident #16's OOH-DNR included the witness 2 signature, physician license number, and physician date the document was signed. 3. The facility did not ensure Resident #24's OOH-DNR included the witness 1 signature. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 05/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #4's OOH-DNR form dated 10/10/2016 revealed a missing signature and date by the physician. 2. Record review of Resident #16's face sheet, dated 11/02/2023, indicated Resident #16 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Record review of Resident #16's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 09/24/2021. Record review of the quarterly MDS assessment dated [DATE], indicated Resident #16 understood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 6 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some others and made himself understood. The assessment indicated Resident #16 had a BIMS score of 11, which indicated his cognition was moderately impaired. Record review of the Resident #16's care plan, revised on 10/15/2021, indicated Resident #16 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #16's OOH-DNR form dated 09/22/2021 revealed a missing witness 2 signature, physician license number, and physician date. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for code status: DNR with an order date 08/01/2023. Record review of the significant change in status MDS assessment dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. Record review of the Resident #24's care plan, revised on 08/13/2023, indicated Resident #24 requested a code status of DNR. The care plan interventions included, inform staff of code status, make sure that the code status is signed by resident or responsible party, MD, and in the active medical record and the social services designee will re-evaluate Advanced Directive needs on a quarterly/annual basis or as needed. Record review of Resident #24's OOH-DNR form dated 07/31/2023 revealed a missing witness 1 signature. During an interview and record review on 11/01/2023 at 1:25 p.m., the Director of Resident Support Services stated she was responsible for completing DNRs. After reviewing Resident #4's electronic medical record, the Director of Resident Support Services stated Resident #4 OOH-DNR was missing a signature and date by the physician. After Resident #16's electronic medical record, the Director of Resident Support Services stated Resident #16 OOH-DNR was missing witness 2 signature, physician license number, and physician date. After Resident #24's electronic medical record, the Director of Resident Support Services stated Resident #24 OOH-DNR was missing witness 1 signature. The Director of Resident Support Services stated she was responsible for overseeing and monitoring by weekly audits. The Director of Resident Support Services stated her last audit was on 10/07/2023. The Director of Resident Support Services stated during the audit she checked the resident code status, care plan, and door label to ensure it was updated in PCC. The Director of Resident Support Services stated during her audits she did not look at the physical documents to ensure it was completely filled out. The Director of Resident Support Services stated it was important to ensure DNRs were completed to respect their wishes. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she expected DNR's to be completely filled out, including signatures, dates, and physician license number. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 7 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated the Director of Resident Support Services was responsible for overseeing and monitoring the DNR. The Administrator stated it was important to ensure the DNR's were completed because, legally the form stated it must have signatures, dates, and physician license number . Record review of the facility's policy titled; Advanced Directives, effective 04/2020 did not address advance directive completion. Event ID: Facility ID: 455944 If continuation sheet Page 8 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 20 residents (Resident #28) reviewed for environment. The facility failed to ensure Resident #28's door was properly functioning. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus (high blood sugars). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #28 was able to make herself understood and understood others. The MDS assessment indicated Resident #28 had a BIMs score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation and interview on 10/30/2023 at 10:18 AM, the surveyor opened Resident #28's door, but the door would not stay open. Resident #28 instructed surveyor to place a trashcan in front of the door to hold it open. Resident #28 said the only way the door stayed open was if something held it open. During an observation and interview on 11/01/2023 at 8:51 AM, room [ROOM NUMBER]'s door was not staying open on its own. Resident #28 said she had told the Director of Plant Operations that the door needed to be fixed because it would not stay open by itself, but he had still not fixed it. Resident #28 said she could not remember how long ago she had told him. During an interview on 11/02/2023 at 9:39 AM, the Director of Plant Operations said he was responsible for fixing the rooms. The Director of Plant Operations said he had tried fixing Resident #28's door but he was not able to fix it completely. The Director of Plant Operations said he had not reached out to anybody to get assistance in fixing Resident #28's door. The Director of Plant Operations said he was sure it could be fixed, but he did not know how. The Director of Plant Operations said it was important for the door to be fixed because in case of an emergency it would be hard for the resident to get out of their room. During an interview on 11/02/2023 at 12:07 PM, the DON said the Director of Plant Operations was responsible for fixing the doors. The DON said if the residents' rooms needed repaired it should be put on the Maintenance Repairs log. The DON said she had known for a little while that Resident #28's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 9 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 door was not staying open on its own. The DON said she did not notify the Director of Plant Operations because she did not think it was an issue. The DON said it was important for the door to be fixed for safety and because it could make it difficult for the resident to get out of the room. During an interview on 11/02/2023 at 1:31 PM, the Administrator said she had not noticed the door to room [ROOM NUMBER] was not staying open on its own. The Administrator said the Director of Plant Operations was responsible for repairs. The Administrator said if a resident reported a door needing to be fixed to the Director of Plant Operations, she expected him to fix it. The Administrator said it was important for the rooms to be in good repairs because it was the resident's home. Record review was performed of the Maintenance logs with Maintenance Repairs needed dated 9/4/23 to 10/31/23, and there were no entries regarding Resident #28's door. Record review of the facility's policy titled, Quality of Life- Homelike Environment, revised May 2017, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 10 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0641 Ensure each resident receives an accurate assessment. 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 an accurate MDS was completed for 1 of 20 residents (Resident's #14) reviewed for MDS assessment accuracy. Residents Affected - Few 1. The facility did not ensure Resident #14's most recent MDS assessment reflected his hospice services during the 14-day look-back period. This failure could place residents at risk for not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #14 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), alcoholic liver disease (spectrum of alcohol-induced liver dysfunction ranging from mild, reversible fatty liver to irreversible liver fibrosis and cirrhosis), and type 2 diabetes mellitus without complications (high blood sugar). Record review of the MDS assessment, dated 09/15/2023, revealed Resident #14 had clear speech and was understood by staff. The MDS revealed Resident #14 was able to understand others. The MDS revealed Resident #14 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #14 had a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS revealed Resident #14 did not receive hospice services during the 14-day look-back period. Record review of the comprehensive care plan, revised 08/13/23, revealed Resident #14 had a terminal prognosis related to liver failure. The interventions included: hospice services initiated on 08/13/23. Record review of the order summary report, dated 10/30/23, revealed Resident #14 had an order that started on 06/06/23, for hospice services. During an interview on 11/02/23 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated she was responsible for ensuring the MDS was accurately filled out. The Clinical Reimbursement Coordinator stated Resident #14 was receiving hospice services. She stated she was unsure why his hospice services were not reflected on the MDS. The Clinical Reimbursement Coordinator stated it was important to ensure the MDS was accurately filled out to represent an accurate picture of the resident to the state agency. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she was responsible for signing the MDS assessment as completed but did not check the MDS for accuracy. The DON stated the Clinical Reimbursement Coordinator was responsible for ensuring the MDS was completed accurately. The MDS accuracy policy was requested. The DON stated corporate staff stated they did not have a facility policy for MDS accuracy, they used the RAI manual. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected the MDS assessment to have been completed accurately. The Administrator stated the Clinical Reimbursement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 11 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinator was responsible for ensuring the MDS was completed accurately. The Administrator stated it was important to ensure the MDS was completed accurately because it was the base for the plan of care. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2019, revealed Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Event ID: Facility ID: 455944 If continuation sheet Page 12 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 2 of 20 residents reviewed for care plans. (Resident #5 and Resident #13) 1. The facility did not implement Resident #5's care plan or accurately reflect her diet preferences. 2. The facility failed to develop and implement a care plan for Resident #13's Hospice care services. These failures could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #5 was a [AGE] year-old female who admitted initially admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (happens when another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and cognitive communication deficit (difficulty with communication that is caused by a problem with cognition). Record review of the MDS assessment, dated 09/08/2023, revealed Resident #5 had clear speech and was understood by staff. The MDS revealed Resident #5 was usually able to understand others. The MDS revealed Resident #5 had a BIMS of 10, which indicated moderately impaired cognition. The MDS revealed Resident #5 had no behaviors or refusal of care. The MDS revealed Resident #5 was independent with eating. The MDS revealed Resident #5 was on a mechanically altered diet. Record review of the comprehensive care plan, initiated on 10/09/2023, revealed Resident #5 was on a mechanical soft diet. The interventions included: dietary manager to monitor/discuss food preferences .diet per orders . The care plan did not address Resident #5's preference to get potato chips with her sandwiches. Record review of the order summary report, dated 10/30/2023, revealed Resident #5 had an order, which started on 09/21/2023, for mechanical soft diet. During an observation and interview on 10/30/2023 beginning at 12:35 PM, Resident #5 had a meal ticket on her meal tray that read mechanical soft. Resident #5 had ruffle potato chips on her plate with approximately 25% missing. Resident #5 stated she did not have any molar teeth in her mouth, which made chewing difficult at times. Resident #5 stated potato chips were soft enough that she was able chew without difficulty. Resident #5 stated she liked potato chips and preferred to have them with her sandwich. During an interview on 11/01/2023 beginning at 4:30 PM, CNA B stated meal trays should have matched (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 13 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dietary tickets. CNA B stated she did not normally pass meal trays on the hall, so was unsure what diet Resident #5 received. CNA B stated she did not really look at the care plan or [NAME] (electronic system that CNAs are able to access that pulls information from the care plan). CNA B stated if she needed to know information about a resident, she asked the nurses or the management nurse staff. CNA B stated it was important to ensure preferences were included on the care plan, so the facility staff knew what was going on with the resident and to provide better care to the residents. During an interview on 11/02/2023 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated the IDT was supposed to have been responsible for ensuring care plans were completed accurately and implemented. The Clinical Reimbursement Coordinator stated resident's dietary preferences should have been included on the care plan. The Clinical Reimbursement Coordinator stated the care plan was a map of the resident's care and should have been followed by the facility staff. The Clinical Reimbursement Coordinator stated the CNAs have access to the care plan through the [NAME] which was information that pulled over from the care plan. The Clinical Reimbursement Coordinator stated CNAs were provided training on the care plan during ADL training. The Clinical Reimbursement Coordinator stated it was important to ensure care plans included resident's preferences, so the staff understood how to take of the residents. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated the Clinical Reimbursement Coordinator was responsible for ensuring dietary preferences were included in the care plan. The DON stated the care plan should have been implemented by the facility staff. The DON stated it was important to ensure dietary preferences were included on the care plan and the care plan was implemented to cover the facility with regulation and so the facility staff knew what was going on with the residents. The policy for comprehensive care plan was requested and not provided upon exit of the facility. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she did not believe every single resident preference should have been included on the care plan. The Administrator stated Resident #5 was on a mechanical soft diet because of her personal preference and choice. The Administrator stated it was her right to have chips if she wanted them, even if the care plan and physician orders did not specify it. The Administrator stated she did not know where the information should have been documented, she guessed it should have been included on the care plan. 2. Record review of Resident #13's face sheet, dated 11/01/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS assessment dated [DATE] indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 14 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. Record review of the care plan last revised on 07/07/2023 indicated Resident #13 had no care plan for hospice services. Record review of Resident #13's order summary report with a date range of 11/01/2023 to 02/27/2023 indicated admit to Hospice as of 09/28/2023. During an interview on 11/02/2023 at 9:35 AM, the MDS Coordinator stated the IDT team was responsible for the care plan, but she ensured that it was complete. The MDS Coordinator stated she was aware that Resident #13 had hospice services. The MDS Coordinator stated Resident #13 should have had interventions in her care plan to hospice services. The MDS Coordinator stated she made a mistake and did not care plan it. The MDS Coordinator stated it was important for Resident #13 to have hospice services on the care plans to ensure appropriate person-centered care. During an interview on 11/02/2023 at 01:00 PM, the DON stated the MDS Coordinator was responsible for ensuring everything for the resident's care was included in the care plans. The DON stated Resident #13 should have had a care plan for hospice services. The DON stated she did not know why it was not in the care plan. The DON stated it was important for Resident #13's hospice services to be included in her care plan because it is the map of providing care of the resident and resulted in continuity of care. During an interview on 11/02/2023 at 01:30 PM, the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include in the care plan hospice services and anything unusual or special for the resident's care. The Administrator stated it was important for Resident #13's hospice services to be included in the care plan so the staff could ensure the resident was receiving appropriate care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 15 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 5 residents reviewed for ADLs. (Resident #41 and Resident #210) Residents Affected - Few 1. The facility did not ensure Resident #41 received nail care. 2. The facility failed to ensure Resident #210 received his shower as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record review of the face sheet, dated 11/01/2023, revealed Resident #41 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of acute on chronic congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), essential hypertension (high blood pressure), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with numbness in hands and feet). Record review of the MDS assessment, dated 09/29/2023, revealed Resident #41 had clear speech and was understood by staff. The MDS revealed Resident #41 was able to understand others. The MDS revealed Resident #41 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #41 had no behaviors or rejection of care. The MDS revealed Resident #41 required a limited one-person assistance with personal hygiene. Record review of the comprehensive care plan, revised on 05/20/2023, revealed Resident #41 had an ADL self-care performance deficit related to disease processes. The interventions included: .check nail length and trim and clean on bath days and as necessary During an observation and interview on 10/30/2023 beginning at 9:25 AM, Resident #41 was sitting up in his wheelchair watching television. Resident #41's fingernails were long, broken, and jagged on the thumb, pointer finger, and middle finger on his right hand. Resident #41 stated the facility staff did not frequently cut his fingernails and knew they were broken. Resident #41 asked the surveyor to pull the nail off where it was broken and hanging off. During an observation on 10/31/2023 beginning at 3:01 PM, Resident #41's fingernails were long, broken, and jagged on the thumb, pointer finger, and middle finger on his right hand. During an observation and interview on 11/01/2023 beginning at 11:37 AM, Resident #41 stated he just returned from his shower. Resident #41's fingernails were long, broken, and jagged on the thumb and middle finger on his right hand. Resident #41 stated the facility staff had not trimmed his fingernails but pulled the fingernail off he asked the surveyor to do. Resident #41 stated the staff had not addressed the other fingernails. During an interview on 11/01/2023 beginning at 4:30 PM, CNA B stated the nurses were responsible for ensuring fingernails were cut and trimmed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 16 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/02/2023 beginning at 10:39 AM, LVN E stated CNAs were responsible for ensuring fingernails were cut and trimmed, unless they had diabetes. LVN E stated the nurses were responsible for trimming Resident #41's nails. LVN E stated broken nails could have caused injury and could have caused problems with the fingers. During an interview on 11/02/2023 beginning at 10:41 AM, the DON stated nail care should have been performed by the CNAs on shower days. The DON stated nail care was performed by the nurses if the resident was diabetic. The DON stated nail care was monitored by performing rounds. The DON stated performing nail care was important for skin, hygiene, dignity, and infection control. During an interview on 11/02/2023 beginning at 11:39 AM, the Administrator stated she expected nursing staff to ensure nail care was completed. The Administrator stated everyone was responsible for monitoring to ensure nail care was completed. The Administrator stated nail care was important because of resident rights. 2. Record review of a face sheet dated 11/02/2023, indicated Resident #210 was an [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), type 2 diabetes mellitus with diabetic chronic kidney disease (chronic condition that affects the way the body processes blood sugar with kidney disease caused by the diabetes), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #210's electronic health record on 11/02/2023 indicated Resident #210's admission MDS assessment was in progress. Record review of Resident #210's care plan last revised 10/26/2023 indicated he had an ADL self-care performance deficit and required extensive assistance by 2 staff members with showering 3 times a week and as necessary. Record review of the Bath Shower Sheets since Resident #210's admission on [DATE] indicated one shower sheet for 10/26/2023. There was no shower sheet for 10/30/2023 and 11/01/2023. During an observation and interview on 10/30/2023 at 3:40 PM, Resident #210 was in his bed and his hair was unkempt, oily, and stuck together. Resident #210 said he had a sponge bath a couple days ago. During an observation and interview on 11/02/2023 at 8:55 AM, Resident #210 said he did not have a bath or shower yesterday and he could not remember when his last one was. Resident #210's hair was oily and stuck together and unkempt. During an interview on 11/02/2023 at 9:08 AM, CNA L said today Resident #210's showers were changed to Tuesday, Thursday, Saturday because he went to dialysis on Monday, Wednesday, Friday. CNA L said prior to today he was supposed to receive his showers on Monday, Wednesday, Friday. CNA L said she worked yesterday (Wednesday, 11/01/2023) on the 200 hall and gave showers. CNA L said she was supposed to give Resident #210 a shower, but she had not given him a shower because he was gone to dialysis. CNA L said he returned from dialysis around noon, and she was busy with lunch. CNA L said she had not informed the following shift she had not had time to give him a shower so they could do it. CNA L said it was important for the residents to receive their baths/showers for them to not smell bad and for their skin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 17 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/02/2023 at 9:25 AM, CNA M said she worked the 200 hall on Monday 11/01/2023. CNA M said she did not know if she was supposed to give Resident #210 a shower. CNA M said she did not pay attention to when Resident #210 was supposed to receive his shower. CNA M said she was supposed to check to see who received a shower on Monday. CNA M said she did not give Resident #210 a shower because he was gone to dialysis, and she did not notify the following shift that he needed a shower. CNA M said it was important for the residents to get their showers, so they did not get germs, or an infection, and to prevent skin break down. During an interview on 11/02/2023 11:14 AM, LVN E said the CNAs were responsible for giving the showers. LVN E said she knew Resident #210 had a shower Friday (10/27/2023), but she was not sure if he had received one Monday (10/30/2023) or Wednesday (11/01/2023). LVN E said if the CNAs are not able to get to a shower when it was scheduled, they should let the following shift know for them to complete it. LVN E said the CNAs brought the bath sheets to the nurse for the nurse to sign it. LVN E said she did not realize Resident #210 had not received a shower. LVN E said it was important for the residents to receive their baths/showers for their skin and for their health. During an interview on 11/02/2023 at 12:10 PM, the DON said all the staff were supposed to be making sure the baths/showers were done. The DON said the CNAs were supposed to do what was on the schedule and the nurses were supposed to follow up and ensure the baths/showers were completed. The DON said she was responsible for monitoring that the showers were completed. The DON said she depended on their staff to complete their assignments. The DON said she made rounds every day to make sure people looked clean and well groomed. The DON said she had noticed issues with shower and was trying to address them. The DON said it was important for the residents to get their showers/baths for their hygiene, skin integrity, dignity, and to prevent infections. The DON said she was not aware Resident #210 had not received his showers as scheduled. The DON said if the CNAs were not able to do his shower because he was at dialysis, they should have let the next shift know so they could do it. During an interview on 11/02/2023 at 1:32 PM, the Administrator said the charge nurses were responsible for ensuring the showers were done. The Administrator said she expected for the residents to receive their showers as scheduled. The Administrator said it was important for the residents to receive their showers for them to maintain good hygiene. Record review of the facility's policy titled, Quality of Life- Resident Self Determination and Participation, revised December 2016, indicated, . Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including: a. Daily routine . and bathing schedules; b. Personal care needs, such as bathing methods, grooming styles and dress . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 18 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some 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 observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 6 of 20 residents (Resident #8, Resident #13, Resident #19, Resident #25, Resident #47, and Resident #52) reviewed for accidents and supervision. The facility did not ensure Resident #52 smoked in the designated smoking area while being supervised during the smoke break. The facility did not ensure PTA F used the gait belt appropriately while ambulating Resident #25. The facility failed to ensure the safety of Resident #13 by not moving the Resident to another location/bed prior to removing/working on the bed. The facility failed to properly store aerosol can with a labeled Lavender Scent Deodorizer Spray leaving them on Resident #47's dresser. The facility failed to properly store 3 air freshener sprays and 1 container of disinfectant wipes leaving them on the bottom shelf of a stand at the foot of the bed in Resident #8's room. The facility failed to properly store razors leaving them on top of Resident #19's dresser. These failures could place residents at an increased risk for injury. Findings included: 1. Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 currently used tobacco. Record review of the comprehensive care plan, initiated on 05/18/23, revealed Resident #52 smoked. The goals included: Resident will have supervised smoking privileges to minimize safety risks. The interventions included: Resident will smoke only in designated smoking area with access to appropriate smoking receptacles. Record review of Resident #52's Safe Smoking Assessment, dated 07/30/23, revealed The resident requires direct supervision while smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 19 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some Record review of the list of designated smoking times and staff responsible for supervising the smoke break, undated, revealed housekeeping staff, dietary staff, and the Social Worker were responsible for supervising the designated smoking breaks. During an observation on 10/31/23 beginning at 3:01 PM, multiple residents were outside in the designated smoking area. The Social Worker was supervising the smoke break and was sitting in a metal chair in the designated smoking area. Resident #52 was sitting up in her wheelchair, outside the designated smoking area on the sidewalk near a grassy area and was approximately 20 feet from a large propane tank. Resident #52 was observed smoking a red-tipped cigarette and flicking her ashes on the ground. The propane tank was in the grass with a metal chain-link fence around it. There was a large sign that read PROPANE: No Smoking; No Open Flames. There were approximately 11 red-tipped cigarette butts in the grass where Resident #52 was sitting. During an observation and interview on 10/31/23 at 3:38 PM, the Administrator accompanied the surveyor into the smoking area. There were approximately 11 red-tipped cigarette butts in the grass approximately 20 feet away from the propane tank. The Administrator stated Resident #52 should not have been smoking outside the designated smoking area. The Administrator stated cigarette butts should not have been thrown on the ground or in the grass. The Administrator stated she would provide in-service education to the facility staff. During an interview on 10/31/23 beginning at 4:06 PM, Food Service Manager C stated she supervised smoke breaks some of the scheduled times. Food Service Manager C stated the residents stayed inside the black gate during smoking breaks, which indicated the designated smoking area. Food Service Manager C stated during the smoke breaks she supervised; no residents had smoked outside the designated smoking area near the propane tank. Food Service Manager C stated she stayed outside with the residents until they were finished smoking. During an interview on 10/31/23 beginning at 4:08 PM, Resident #52 stated she normally sat in the designated smoking area. Resident #52 stated she had been sitting outside the smoking area during the last few days because it was cold, and she wanted to sit in the sun. Resident #52 stated no staff members had attempted to encourage her to sit in the designated smoking area. During an interview on 10/31/23 beginning at 4:13 PM, Community Cleanliness Provider A stated she normally assisted residents to smoke during the 8:30 AM, 10:30 AM, and 1:15 PM smoke breaks. Community Cleanliness Provider A stated the residents normally sit under the covered patio with the black fence around it. Community Cleanliness Provider A stated she had not observed any residents or staff smoking outside the designated smoking area near the propane tank. During an interview on 10/31/23 beginning at 4:23 PM, the Social Worker stated she was responsible for supervising residents during the 3:00 PM smoke break. The Social Worker stated Resident #52 usually sat outside the designated smoking area because she wanted to sit in the sun, but she stated Resident #52 did not normally smoke. The Social Worker stated she had not noticed Resident #52 smoking outside the designated area during the 3:00 PM smoke break. The Social Worker stated an explosion or fire could have happened if residents smoked outside the designated smoking area and threw their cigarette butts on the ground. Record review of the Smoking policy, undated, revealed Smoking by residents is allowed outside in designated, marked smoking areas . The policy further revealed IDT will develop an individualized plan for .required supervision for residents who smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 20 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some 2. Record review of the face sheet, dated 11/01/23, revealed Resident #25 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema (complication of high blood sugar where blood vessels in the eye are damaged causing swelling), legal blindness (unable to see), unsteadiness of feet, difficulty in walking, ataxia (loss of coordination of voluntary muscle movements), and muscle wasting and atrophy (loss of muscle and muscle mass leading to its shrinking and weakening). Record review of the MDS assessment, dated 09/22/23, revealed Resident #25 had clear speech and was understood by staff. The MDS revealed Resident #25 was able to understand others. The MDS revealed Resident #25 had a BIMS of 14, which indicated no cognitive impairment. The MDS revealed Resident #25 required an extensive, one-person assistance with transfers, walking, and dressing. The MDS revealed Resident #25 was not steady and only able to stabilize with staff assistance for walking, turning around, and moving from a seated to standing position. Record review of the comprehensive care plan, revised on 10/05/23, revealed Resident #25 had an ADL self-care performance deficit related to his disease processes. The interventions did not address walking. The interventions for transfers included: .requires extensive assistance by 2 staff to move between surfaces as necessary. During an observation on 10/30/23 beginning at 10:06 AM, PTA F assisted Resident #25 with walking down the hallway using his walker. Resident #25 had a gait belt around his upper body. The gait belt was loose, hanging low, and twisted in the middle of his back. PTA F was holding Resident #25's shorts to guide him. PTA F was not holding onto the gait belt. During an interview on 11/02/23 beginning at 8:56 AM, PTA D stated PTA F was not scheduled to work until 11/03/23. PTA D was unable to provide PTA F's phone number at the time of the interview. PTA D stated gait belts should have been placed below the ribs or above the breasts under the armpits depending on the person. PTA D stated the gait belt should have been snug but not too tight. PTA D stated Resident #25 was in between independent and contact guard assistance. PTA D stated Resident #25 required hands on assistance sometimes. PTA D stated staff should not hold onto residents' pants during transfers unless they were falling. PTA D stated if the clothing was loose then he would have held both the pants and the gait belt while walking the resident. PTA D stated the gait belt should not have been twisted when placed on the resident. PTA D stated it was important to ensure the gait belt was placed appropriately to prevent skin injury and potential falls. During an interview on 11/02/23 beginning at 9:28 AM, the Director of Rehab stated the gait belt should be applied around the waist snuggly. The Director of Rehab stated the gait belt should be snug but comfortable for the resident. The Director of Rehab stated the gait belt should not have been twisted, but flat against the residents clothing. The Director of Rehab stated staff should have been holding the gait belt while walking with a resident. The Director of Rehab stated she had only been in the director role for approximately six months and gait belt training had not been performed by the therapy department. The Director of Rehab stated it was important to ensure the gait belt was appropriately placed to prevent an injury to the resident. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to ensure the gait belt was used appropriately. The DON stated the gait belt should not have been twisted or applied loosely. The DON stated the staff should have held the gait belt while ambulating Resident #25. The DON stated gait belt training was provided at least annually and staff would have been retrained if issues were observed. The DON stated it was important to ensure staff was using gait belts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 21 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 appropriately for resident safety. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected therapy staff to follow their practices and procedures for appropriately applying the gait belt. The Administrator stated the therapy manager was responsible for monitoring to ensure gait belts were used appropriately. The Administrator stated it was important to ensure gait belts were used appropriately for resident safety. Residents Affected - Some Record review of an e-mail, accessed on 11/06/23, revealed a statement from PTA D sent by the Administrator as additional evidence. The statement from PTA D revealed In reference to the tag . received for the gait training I performed with the resident in room [ROOM NUMBER]: I was holding onto the patient's shorts elastic waist band because his shorts are loose and the resident requested that I hold them up otherwise they (his shorts) would fall to the ground while ambulating which would impose a safety concern on its own as well as degrade the patient's inherent right to dignity as he would be exposed to the other residents in the hallway. Furthermore, on this topic, this resident is legally blind and requires the use of tactile cues for navigation in a dynamic environment, such as a hallway, and I am unable to provide the most optimum tactile cues by only holding onto the gait belt. Also, this resident typically does not require the constant use of Contact Guard Assistance (holding onto the gait belt) for gait training which would further explain why I was not directly holding onto the gait belt. The gait belt was merely placed on the resident because it is best practice for safety. Rarely, if ever, does this resident require the use of holding onto the gait belt for balance corrections. During a telephone interview on 11/06/23 beginning at 9:57 AM, PTA D stated Resident #25 did not normally use a gait belt. PTA D stated the gait belt was only applied for safety reasons. PTA D stated on 10/30/23 Resident #25 requested him to hold onto his shorts so they did not fall. PTA D stated Resident #25 did not request his shorts to be changed. PTA D stated the gait belt should have been applied snuggly but Resident #25 requested the gait belt not be tight. PTA D stated the gait belt should not have been twisted. PTA D stated it was important to ensure the gait belt was applied properly to prevent injury to the resident in case it needed to be used. Record review of the Safe Lifting and Movement of Residents policy, revised July 2017, revealed .this facility uses appropriate techniques and devices to lift and move residents. The policy did not address the proper use of a gait belt when assisting residents with ambulation. 3. Record review of Resident #13's face sheet, dated 11/01/2023, indicated an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 22 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 Record review of the MDS Resident Assessment and Care Screen indicated 09/18/2023 indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. Residents Affected - Some During an observation on 10/31/2023 at 10:32 AM, the Maintenance Supervisor was lying on the floor with the front portion of his body under Resident #13's left side of bed. The Maintenance Supervisor had a tool in hand and working on the bed. Resident #13's bed was in high position. During an observation on 11/01/2023 at 4:32 PM, the right-side rail had been removed from Resident #13's bed. During an interview on 11/02/23 at 12:07 PM, the DON said usually we take the residents out of the bed to remove the assist rails. The DON said Resident #13 no longer used the rails for bed mobility since she has declined. The DON said the facility had recently gone through and did assessments to make sure the resident's qualified to have the assistance rails and more than likely that's what the maintenance supervisor was doing at that time. The DON said the Resident should not have been in the bed while the work was being done with the bed in high position and the maintenance supervisor under it. The DON said it was not safe for resident or the maintenance supervisor. During an interview on 11/02/2023 at 12:32 PM, the Maintenance Supervisor said he was tightening the rail on resident #13's bed. He said Resident #13 was left in the bed while he made the repairs because he was not disturbing her, and it was not a safety issue. The Maintenance Supervisor said it was the only way to do the repairs to his knowledge because the resident cannot get out of the bed as she is in the dying process. During an interview on 11/02/2023 at 01:30, the Administrator said they would not have move Resident #13 out of bed for the bedrail repairs because she is in the dying process and would not want to cause discomfort and pain. 4. Record review of Resident #47's face sheet, dated 11/01/2023, indicated a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Prostate (abnormal growth where cells divide uncontrollably and destroy bodily tissue), Secondary Malignant Neoplasm of other Parts of Nervous System, Acquired Absence of other Genital Organ (missing one or several genitals due to injury or operation), Paraplegia (paralysis of the lower body), other cord compression, essential Hypertension (high blood pressure), Neuromuscular Dysfunction of Bladder (lack of bladder control related the muscles and nerves do not work well together). Record review of the MDS Resident Assessment and Care Screen indicated 08/30/2023 indicated Resident #47 was able to make self-understood and understood others. The MDS assessment indicated Resident #47 had a BIMS score of 14, which indicated cognitively intact. The MDS assessment Indicated Resident #47 required limited assistance for bed mobility, dressing, and personal hygiene and extensive assistance for transfers and toilet use. During an observation and interview on 10/30/2023 at 1:08 PM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. Resident #47 said he had won the aerosol spray during a Bingo game. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 23 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some During an observation on 10/31/2023 at 09:10 AM, an aerosol can with a labeled Lavender Scent Deodorizer Spray was sitting on the dresser in Resident #47's room. 5. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. All items were labeled keep out of reach of children. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had 3 air freshener sprays and 1 container of disinfectant wipes on the bottom shelf of the stand at the foot of her bed. 6. Record review of Resident #19's Order Summary Report indicated he was [AGE] years old and admitted on [DATE] with diagnoses which included chronic respiratory failure with hypercapnia (carbon dioxide level is abnormally high in the blood causing respiratory failure), major depressive disorder recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus with foot ulcer (high blood sugar levels in the blood with a foot wound). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #19 was able to make himself understood and understood others. The MDS assessment indicated Resident #19 had a BIMs score of 12, which indicated his cognition was moderately impaired. During an observation on 10/30/2023 at 10:37 AM, Resident #19 had razors on his bedside table. Resident #19 said his family member had provided them for him and the CNAs used them to shave him. During an observation on 11/01/2023 at 09:55 AM, Resident #19 had razors on his bedside table. During an interview on 11/01/2023 at 10:01 AM, LVN E said Resident #8 should not have air freshener sprays and disinfectant wipes in her room. LVN E said Resident #8's family must have [NAME] the items into Resident #8's rooms, and she had not noticed them in there. LVN E said all the staff were responsible for ensuring the residents rooms did not have room sprays and disinfectant wipes in them. LVN E said the residents were not supposed to have razors on the dresser. LVN E said she had not seen Resident #19 had razors on his dresser. LVN E said the CNAs should ensure they were not left in the room accessible to the residents. LVN E said it was important for the residents to not keep room sprays because they could be flammable, and it was a danger to the residents. LVN E said the residents should not have disinfectant wipes in their rooms because the residents could confuse them with wet wipes and use the wrong wipe and cause harm to themselves. LVN E said wandering and confused residents could go in the resident's room and harm themselves. LVN E said it was important for the razors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 24 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Some to not be left on the resident's dresser because another resident could pick one up and cut themselves and for safety. LVN E said Resident #19 could shave himself without the staff knowing and cut himself and bleed for an extended period before the staff found out. During an interview on 11/01/2023 at 10:33 AM, the ADON said air freshener sprays and disinfectant wipes should not be in the residents' rooms. The ADON said razors were not allowed at the bedside. The ADON said she checked Resident #8's and Resident #19's rooms daily as part of her rounds and she had not noticed the room sprays, disinfectant wipes or razors. The ADON said it was important for the residents to not keep room sprays in their rooms so they would not get something in their eyes or drink something they were not supposed to for their safety. The ADON said it was important for the disinfectant wipes to not be in the residents' rooms because they have chemicals that could harm the residents. The ADON said it was important to not keep razors at the bedside because the residents could be on blood thinners and injure themselves and other residents that did need their hands on the razors could get a hold of them. During an interview on 11/02/2023 at 12:32 PM, the DON said she encouraged the residents to not have room sprays and disinfectant wipes in their rooms. The DON said if they did have them in their rooms these items should be stored somewhere safe and out of reach of other residents. The DON said Resident #8 should not have had room sprays and disinfectant wipes in her room. The DON said it was important for the room sprays and disinfectant wipes to be stored properly and out of reach of other residents for the resident's safety. The DON said she did not want a confused resident to get a hold of these items and hurt themselves. The DON said razors should not be left on top of the dresser. The DON said it was important for razors to be out of the reach of the residents because they could hurt themselves or others. The DON said it was all the staff's responsibility to keep room sprays, disinfectant wipes, and razors out of the residents reach for their safety. During an interview on 11/02/2023 at 1:33 PM, the Administrator said room sprays and disinfectant wipes were allowed in the rooms because it was the residents choice to keep them in their rooms. The Administrator said it was important for room sprays and disinfectant wipes to be out of reach of other residents because if they should not have it, they would not get it. The Administrator said residents were allowed to keep razors at the bedside if they were capable of keeping them. The Administrator said the razors at the bedside could pose a risk to other residents, but there were so many hazards that could be dangerous in the residents' rooms. The Administrator said all the staff were responsible for ensuring the residents environment was safe for them. During an interview on 11/02/2023 at 1:10 PM, the DON said she could not find a policy regarding accidents and hazards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 25 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 20 residents (Residents #28) reviewed for pharmacy services. The facility failed to ensure Resident #28 received insulin as prescribed. The facility failed to ensure Resident #28's blood sugar was rechecked in an hour. These failures could place residents at risk for hospitalizations, not receiving services to meet their needs, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/02/2023 indicated Resident #28 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness and paralysis of the right side of the body following a stroke), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and type 2 diabetes mellitus (high blood sugars). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #28 was able to make herself understood and understood others. The MDS assessment indicated Resident #28 had a BIMs score of 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #28 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of Resident #28's Order Summary Report dated 10/31/2023, indicated orders for Fingerstick blood sugars 3 times a day before meals Humulin R Solution (Insulin Regular Human medication used to lower blood sugar) inject per sliding scale: if blood sugar 0 - 70 give 25 ml of orange juice; blood sugar 151 - 200 give 3 units; blood sugar 201 - 250 give 5 units; blood sugar 251 - 300 give 7 units; blood sugar 301 - 400 give 11 units; blood sugar more than 401 give 11 units recheck in 2 hours, if over 400, call the medical director or nurse practitioner, subcutaneously (injection under the skin) every 8 hours as needed for diabetes mellitus with a start date of 02/25/21 Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine medication used to lower blood sugar) Inject 60 units subcutaneously two times a day for diabetes with a start date of 05/31/23. Record review of Resident #28's MAR for October 2023 indicated: 10/27/2023 at 4:30 PM LVN N documented a blood sugar of 422 no Humulin R was administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 26 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/29/2023 at 5:00 AM LVN K documented a blood sugar of 449 and administered 11 units of Humulin R as ordered. Record review of Resident #28's progress notes indicated: 10/27/2023 at 8:23 PM LVN N documented the Medical Director was notified of elevated blood sugar 422 at 2:00 PM. Blood sugar reassessed and indicated to have improved blood sugar 391. 10/29/2023 at 5:31 AM LVN K documented medical director noted, recheck in 1 hour. Regarding the blood sugar of 449. The progress notes for 10/29/2023 did not indicate Resident #28's blood sugar was rechecked in 1 hour. Record review of Resident #28's care plan with a target date of 11/11/2023 indicated to perform blood sugar checks as ordered, administer Humulin R per the sliding scale and Lantus as ordered by the doctor. During an interview on 11/01/2023 at 4:17 PM, LVN K said on 10/29/2023 Resident #28's blood sugar was 449 at 5:31 AM. LVN K said he notified the Medical Director, and the Medical Director instructed him to administer the Humulin R per the sliding scale and recheck Resident #28's blood sugar in 1 hour. LVN K said he did not recheck the blood sugar in an hour because he went home. LVN K said he worked from 10 PM to 6 AM, and an hour later was after his shift ended. LVN K said he forgot to tell the nurse that relieved him to recheck Resident #28's blood sugar. LVN K said it was important to follow the doctor's orders and recheck the blood sugar to make sure the blood sugar was coming down, and it was at a safe level. LVN K said high blood sugars could lead to a diabetic coma. During an interview on 11/02/2023 at 12:15 PM, LVN N said Resident #28's blood sugar was elevated on 10/27/2023, and she notified the Medical Director. LVN N said the Medical Director never responded to her text message. LVN N said this was her way to communicate with the Medical Director and he usually responded. LVN N said she did not try to call the Medical Director again because Resident #28 was due to receive her Lantus 2.5 hours after she checked Resident #28's blood sugar. LVN N said she had not administered the Humulin R as ordered because the computer system was telling her it was too early to administer it. LVN N said she did not notify the DON or attempt to call her to receive advise regarding this. LVN said it was her mistake. LVN N said it was important to administer insulin as prescribed because if the insulin was not administered the residents blood sugar could keep getting higher and it could get pretty bad. During an interview on 11/02/2023 at 12:48 PM, the DON said she was not aware LVN N had not administered insulin as prescribed and had not received a response from the Medical Director when she notified him of Resident #28's high blood sugar on 10/27/2023. The DON said she was not aware LVN K had not rechecked or notified the nurse that relieved him that Resident #28's blood sugar needed to be rechecked on 10/29/2023. The DON said if the Medical Director did not respond to a text message the nurses should call him, and if he still did not answer they should administer the insulin per the orders, notify her, and check the residents blood sugar more frequently. The DON said LVN N should have notified her she was receiving an error message in the computer system and administered the insulin per the orders. The DON said LVN K should have passed on in report that Resident #28's blood sugar needed to be rechecked, so the following nurse could follow up on it. The DON said she was responsible for ensuring the nurses were administering medications as prescribed and following the doctors' orders. The DON said she monitored the nurses by randomly checking the nurse's documentation, the MARs, and completing skills check offs. The DON said they had a standards of care weekly meeting and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 27 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm they went through the residents' blood sugars to see whose blood sugars were high and what interventions were done. The DON said it was important to administer insulin and follow up on high blood sugars to manage the residents' diabetes appropriately and to ensure the insulin was effective. The DON said high blood sugars could result in the residents being hospitalized . The DON said it was important to follow the physician's orders because they were in place for a reason to give the residents the best care possible. Residents Affected - Few During an interview on 11/02/2023 at 1:37 PM, the Administrator said the charge nurses were responsible for following the physician orders and administering medications as prescribed. The Administrator said she expected for the charge nurses to do this. The Administrator said she did not know the outcome of not following the physician orders and not administering medications as prescribed because she was not clinical. Record review of the facility's policy titled, General Guidelines for Medication Administration, last revised 08/2020, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 28 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 20 residents (Residents #4, #9 and #24) reviewed for medical records. 1. The facility did not ensure Resident #4's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #4's side effects were adequately monitored regarding her antianxiety, antidepressant and antipsychotic medications. 2. The facility did not ensure Resident #9's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #9's side effects were adequately monitored regarding her antianxiety and antidepressant medications. 3. The facility did not ensure Resident #24's behaviors were adequately monitored regarding her antianxiety medication. The facility did not ensure Resident #24's side effects were adequately monitored regarding her antianxiety medication. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: 1. Record review of Resident #4's face sheet, dated 11/02/2023, indicated Resident #4 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included anxiety/major depressive disorder, and schizophrenia (mental condition involving a breakdown in the relation between though, emotion, and behavior). Record review of Resident #4's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 5 mg 1 tablet three times a day for anxiety with a start date of 10/29/2021 *Duloxetine 20 mg 1 tablet daily for depression with a start date of 06/10/2022 *Risperidone 0.5 mg 1 tablet at bedtime for schizophrenia with a start date of 06/07/2023 Record review of the quarterly MDS dated [DATE], indicated Resident #4 usually understood others and usually made herself understood. The assessment indicated Resident #4 had a BIMS score of 15, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 29 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which indicated her cognition was intact. The assessment indicated Resident #4 received antianxiety, antidepressants and antipsychotic medications during the 7 day look back period. Record review of the Resident #4's care plan, revised on 06/27/2022, indicated Resident #4 had a behavior related to schizophrenia and used an antianxiety and antidepressant medication. The care plan interventions included, administer Duloxetine as ordered by physician, monitor/document side effects/effectiveness every shift, administer antianxiety medication as ordered by physician, monitor for side effects/effectiveness every shift, and monitor behavior episodes and attempt to determine underlying cause. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 2. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included major depressive and anxiety disorder. Record review of Resident #9's physician order summary report, dated 11/02/2023, indicated an active physician's order for: *Buspirone 10 mg 1 tablet by mouth two times a day for anxiety with a start date of 12/01/2021 * Citalopram Hydrobromide 10 mg 1 tablet by mouth daily for depression with a start date of 06/07/2022 *Trazadone 100 mg 1 tablet at bedtime for depression with a start date of 01/11/2022 Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The assessment indicated Resident #9 received antianxiety and antidepressant medications during the 7 day look back period. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 used an antianxiety and antidepressant medication. The care plan interventions included, administer antidepressant and antianxiety medications as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. 3. Record review of Resident #24's face sheet, dated 11/02/2023, indicated Resident #24 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition. The face sheet did not address the anxiety diagnosis. Record review of Resident #24's physician order summary report, dated 11/02/2023, indicated an active physician's order for: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 30 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0758 * Alprazolam 0.25 mg 1 tablet by mouth two times a day for anxiety with a start date of 08/03/2023 Level of Harm - Minimal harm or potential for actual harm * Alprazolam 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety with a start date of 10/26/2023 Residents Affected - Some Record review of the significant change in status MDS dated [DATE], indicated Resident #24 understood others and made herself understood. The assessment indicated Resident #24 had a BIMS score of 10, which indicated her cognition was moderately impaired. The assessment indicated Resident #9 received antianxiety medication during the 7 day look back period. Record review of the Resident #24's care plan, revised on 08/15/2023, indicated Resident #24 used an antianxiety medication. The care plan interventions included, administer antianxiety medication as ordered by physician, and monitor/document side effects/effectiveness every shift. Record review of the MAR dated 10/01/2023-10/31/2023 revealed no behaviors (panic attacks, yelling or screaming) or side effects (hypotension, increased anxiety, or sedation) were documented as evidence by NA and blank spaces. During an interview on 11/01/2023 at 1:44 p.m., LVN E stated the charge nurses were responsible for monitoring/documenting behaviors and side effects in PCC (electronic medical record). LVN E stated psychotropic medications required to be monitored to ensure the medication was effective and to show whether or not the medication was required. LVN E stated if the resident was not having any behaviors, 0 should be documented or if the resident was exhibiting s/sx, 1, 2 or 3 should be documented. LVN E stated it was not appropriate to document NA to indicate if the resident was exhibiting side effects or behaviors. LVN E stated it was important to ensure there was not an error in documentation to prevent the medication from getting discontinued and putting the residents at risk for increased depression, anxiety, and psychotic episodes. LVN E stated the risk associated with error in documentation was extended problems such as tardive dyskinesia, N/V, rash and swelling. During an interview on 11/02/2023 at 9:11 a.m., the DON stated she expected the nurses to monitor for side effects and behaviors by properly documenting in the resident's chart. The DON stated the nurses should assessed the residents for side effects and behaviors for psychotic medications and chart if the resident was exhibiting side effects or behaviors such as panic attacks, yelling, screaming, or cursing. The DON stated if the resident was not exhibiting any s/sx the charge nurses were to document 0 which indicated no side effects/behaviors. The DON stated the monitoring should be 0,1, 2 or 3 and not NA to indicate side effects/behaviors. The DON stated she expected every shift to monitor and document for any side effects or behaviors. The DON stated there was not a consistent procedure for monitoring to ensure follow up for complete documentation. The DON stated it was important to monitor for side effects/behaviors to properly treat the resident and to ensure medication was effective. The DON stated the risk associated with error in documentation was residents not properly being treated for the psychotic medication. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated she was referring to the DON regarding psychotropic medications documentation because she was responsible for monitoring that system. During an interview on 11/02/2023 at 11:57 a.m., the Regional MDS nurse stated there was not a policy and procedure regarding behavior monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 31 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 1 of 9 residents reviewed for insulin administration. (Resident #52) Residents Affected - Some The facility did not ensure LVN P and RN Q administered Resident #52's Humalog (insulin lispro) KwikPen (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 was taking insulin and an indication was noted. The MDS revealed Resident #52 received an insulin injection 3 out of 7 days during the look-back period. Record review of the comprehensive care plan, initiated on 04/27/23, revealed Resident #52 was at risk for complication related to diagnosis of type 2 diabetes mellitus. The interventions included: Diabetes medication as ordered by doctor. Record review of the order summary report, dated 10/31/23, revealed Resident #52 had the following orders: Insulin lispro injection - inject 5 units subcutaneously before meals and at bedtime for diabetes, which started on 10/08/23. Humalog KwikPen 100 units/ML - inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; notify MD if greater than 400 for orders, subcutaneously before meals and at bedtime for diabetes, which started on 10/11/23. Record review of the MAR, dated October 2023 and November 2023, revealed Resident #52 received insulin injections daily. Record review of the manufacturer's instructions titled Instruction for Use - Humalog KwikPen (insulin lispro) ., accessed on 11/01/23 at 3:09 PM, revealed Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 32 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 10/31/23 beginning at 4:00 PM, LVN P was standing at her medication cart. LVN P stated she was going to perform a finger stick blood sugar check and administer insulin to Resident #52. LVN P prepared the finger stick blood sugar check and went into Resident #52's room. LVN P stuck Resident #52's finger and obtained a small amount of blood for the test. The result was 295. LVN P returned to the cart to prepare the insulin for Resident #52. LVN P took a Humalog KwikPen with Resident #52's name on it out of the medication cart. LVN P took the lid off the pen and opened the needle tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime the pen (push through 2 units of insulin to remove air from the needle). LVN P administered 5 units of insulin to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart and realized she administered the incorrect amount of insulin. LVN P stated she should have administered 6 units of the Humalog KwikPen according to the sliding scale and then another 5 units of the insulin lispro pen. LVN P took the Humalog KwikPen and applied another needle tip. LVN P rotated the dial to 1 unit, to equal a total of 6 units. LVN P then obtained an insulin lispro pen with Resident #52's name on it from the medication cart. LVN P took the lid off the pen and opened the need tip to apply to the pen. LVN P applied the needle and rotated the dial to 5 units. LVN P did not prime either pen while preparing the insulin for administration. LVN P administered 1 unit of the Humalog KwikPen and 5 units of the insulin lispro pen to Resident #52's left lower quadrant of her abdomen. LVN P returned to the medication cart. LVN P stated she noticed Resident #52 had two different orders for insulin administration. LVN P stated Resident #52 received 5 units of insulin routinely and then received additional insulin based on the results of her finger stick blood sugar. LVN P stated Resident #52 had two different insulin pens on the medication cart, Humalog, and insulin lispro (the same medication). During an observation and interview on 11/01/23 beginning at 4:08 PM, RN Q was standing at her medication cart. RN Q stated she had obtained Resident #52's finger stick blood sugar and the result was 260. RN Q obtained the Humalog KwikPen with Resident #52's name on it from the medication cart. RN Q took the lid off the pen and opened the needle tip to apply to the pen. RN Q applied the needle and rotated the dial to 11 units. LVN P stated she combined the routinely ordered 5 units with the sliding scale requirement of 6 units to equal a total of 11 units. RN Q did not prime the pen (push through 2 units of insulin to remove air from the needle). RN Q stated she did not normally prime the insulin pen prior to administration. RN Q stated she was believed they were required to prime the insulin pen before the initial dose only. During an interview on 11/02/23 beginning at 9:45 AM, LVN P stated the process for administering an insulin injection was to look at the orders, find the correct pen with the resident's name on it, dial the pen to the correct amount and administer the insulin. LVN P stated she did not normally prime the insulin pen prior to each use. LVN P stated she would only have primed the pen if it was the initial use. LVN P stated she was unaware the manufacturer's instructions on the insulin pen required priming the pen before each use. LVN P stated she had received training in the past for the insulin pen, approximately 2011 or 2012. LVN P stated it was important to ensure the manufacturer's instructions were followed to ensure the residents received the accurate dosage of medication. LVN P stated if the accurate dose was not received, the diabetes could not have been managed. LVN P stated it could have made the blood sugars high or low. During an interview on 11/02/23 beginning at 9:56 AM, the Pharmacy Consultant stated an insulin pen should definitely have been primed prior to the first use. The Pharmacy Consultant stated if facility staff primed the insulin pen before each use, they would run out of the medication. The Pharmacy Consultant stated she was driving but she believed the manufacturer's instructions were to prime only before the initial dose. The Pharmacy Consultant stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 33 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it was important to prime the pen to ensure it was working correctly and the residents received the correct dose of insulin. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected the nursing staff to follow policy, procedure, and manufacturer's instructions when administering insulin pens. The DON stated training was provided for administering insulin approximately at the beginning of the year. The DON stated to her knowledge she did not recall that the training addressed using the insulin pen, only the insulin vials. The DON stated the nurse management was responsible for monitoring to ensure insulin was administered correctly to the residents. The DON stated it was monitored by random observations and during monthly visits by the pharmacy consultant. The DON stated it was important to ensure insulin was administered according to the manufacturer's instructions, so the residents received the correct dosage of insulin. The DON stated receiving the incorrect dosage of insulin could have caused the blood sugars to become high or low. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected nursing staff to follow manufacturer's instructions when administering the insulin pens. The Administrator stated the DON was responsible for monitoring to ensure the nursing staff administered insulin correctly. The Administrator stated it was important to ensure insulin was administered according to manufacturer's instructions because staff was supposed to do things the correct way. The Administrator stated there were procedures to follow. Record review of the Administration Procedures for All Medications policy, revised 08/2020, revealed .consult a drug reference, manufacturer package insert, or pharmacist for more information . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 34 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 20 residents (Resident #8, Resident #9, and Resident #40) and 1 of 1 empty resident's room reviewed for drugs and biologicals. The facility failed to ensure Resident #8's Afrin (nasal spray medication) was stored properly. The facility failed to ensure Resident #40's Azelastine (nasal spray medication) was stored properly. The facility did not ensure a Plavix pill (antiplatelet) was stored in a locked container and original packaging. The facility did not ensure Resident #9's multivitamins, ear drops, and triple antibiotic ointment were properly safe and secured. These failures could place residents at risk of medication misuse and diversion. Findings included: 1. Record review of Resident #8's face sheet dated 11/07/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, moderate, without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic pain syndrome (pain that lasts a long time and affects your mood, sleep, and daily living), and acute kidney failure (sudden and serious condition that affects your kidneys' ability to filter waste and fluid from your blood). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #8 had a BIMS score of 7, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #8 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of the care plan with date initiated 09/14/2023 indicated Resident #8 had impaired cognitive function or impaired thought process to administer medications as ordered. Resident #8's care plan did not indicate she could self-administer medications. During an observation on 10/30/2023 at 4:32 PM, Resident #8 had Afrin nasal spray on her bedside dresser. During an observation on 11/01/2023 at 9:18 AM, Resident #8 had Afrin nasal spray on her bedside dresser. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 35 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Order Summary Report dated 10/31/2023 indicated Resident #8 did not have an order for Afrin. There was no order to indicate Resident #8 was able to self-administer medications. 2. Record review of a face sheet dated 11/02/2023 indicated Resident #40 was an [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia in other diseases classified elsewhere, moderate, other diagnosis without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety ((loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #40 was able to make herself understood and understood others. The MDS assessment indicated Resident #40 had a BIMs score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #40 required supervision for bed mobility, dressing, and toilet use, and limited assistance with transfers and personal hygiene. Record review of the care plan with a target date of 11/11/2023 indicated Resident #40 had impaired cognitive function and loss of memory. Resident #40's care plan did not indicate she could self-administer medications. Record review of Resident #40's Order Summary Report dated 11/02/2023 indicated Resident #40 had an order for Azelastine solution 0.1% 1 spray in both nostrils two times a day with a start date of 09/16/2022. There was no order to indicate Resident #40 could self-administer medications. During an observation and interview on 10/30/2023 at 10:29 AM, Resident #40 had Azelastine on the dresser by her bed. Resident #40 said she used it sometimes when she got the snuffles. During an observation on 10/31/2023 at 9:19 AM, Resident #40 had Azelastine on the dresser by her bed. During an observation on 11/01/2023 at 9:55 AM, Resident #40 had Azelastine on the dresser by her bed. During an interview on 11/01/2023 at 10:07 AM, LVN E said the residents should not have nasal sprays at the bedside. LVN E said the nurses and management staff were responsible for ensuring the residents did not have nasal sprays at the bedside. LVN E said she was not aware Resident #8 and Resident #40 had nasal sprays on their dressers. LVN E said it was important for the residents not to keep medications at the bedside because the resident may not be in the state of mind to self-administer. LVN E said if the resident's mental capacity allowed for them to keep medications in the room, they would have to have a doctor's order. During an interview on 11/01/2023 at 10:33 AM, the ADON said the residents were not allowed to keep nasal sprays at the bedside because they were medications. The ADON said management staff performed daily rounds to check the residents' rooms. The ADON said she had done the rounds on Resident #8 and Resident #40, and she had not noticed they had nasal spray at their bedside. The ADON said it was important for the residents not to keep medications at their bedside because the medications had doses and the staff did not need to allow the residents to use the medication as often as they want, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 36 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0761 and medications required monitoring. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/02/2023 at 12:36 PM, the DON said Resident #8 should not have Afrin in her room, and Resident #40 should not have Azelastine in her room. The DON said those medications should be on the medication carts. The DON said she was not aware those medications were in the residents' rooms. The DON said the department heads, nurses, and CNAs were all responsible for ensuring the residents did not keep medications in their rooms. The DON said it was important for medications to be stored properly for the safety of the residents. Residents Affected - Some During an interview on 11/02/2023 at 1:39 PM, the Administrator said for residents to have medications at the bedside they would have to be assessed for their ability to have it. The Administrator said the IDT was responsible for making sure if medications were at the bedside the residents were appropriately assessed. The Administrator said it was important for them to know if medications were at the resident's bedside because they needed to know what the residents were taking for the resident's safety. 3. During an observation and interview on 10/30/23 beginning at 11:18 AM, a small, round, light pink pill with the letters SG was observed on the ground next to the leg of a chair in an empty resident's room, room [ROOM NUMBER]. The Administrator was notified. The Administrator picked up the pill with a brown paper towel and stated she was going to notify the DON. During an observation and interview on 10/30/23 beginning at 11:33 AM, the DON showed the surveyor the back side of the small, round, light pink pill, which had the numbers 124. The DON stated she looked up the medication and determined it was a Plavix pill, which was an antiplatelet medication. During an interview on 11/01/23 beginning at 4:43 PM, the Director of Environmental Services stated empty rooms were deep cleaned when residents moved out of the room or left the facility. The Director of Environmental Services stated finding medication on the floor was not a common thing, but he had found medication on the floor. The Director of Environmental Services stated when medication was found on the floor, the process was to notify the charge nurse. The Director of Environmental Services stated the empty resident room on Hall 6 was deep cleaned and no medication was observed on the ground. The Director of Environmental Services stated it was important to ensure medication was not left on the floor to ensure medication was accounted for and to ensure the residents received all their medication. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she was unsure how the Plavix pill ended up on the ground in an empty resident room. The DON stated it could have been the last resident to occupy the room or possibly a family member's medication. The DON stated the empty room should have been deep cleaned after the resident moved out or went home. The DON stated she expected the housekeeping staff to ensure the rooms were deep cleaned. The DON stated she expected nursing staff to ensure all medication was administered to a resident. The DON stated she expected staff to notify the nurse if medication was found on the ground. The DON stated medication administration and storage was monitored by random observations and monthly by the pharmacy consultant. The DON stated it was important to ensure medications were properly administered and stored so residents could get the appropriate treatment and to protect other residents from taking medication that did not belong to them. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated there was no medication noticed on the ground the morning on 10/30/23 when she was getting the room ready for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 37 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some survey team. The Administrator stated the room was cleaned and set up that morning. The Administrator stated she checked all areas including drawers, etc. before saying it was ready for use by the survey team. The Administrator stated the surveyor would have been the first to see the pill on the floor and report it to the facility. The Administrator stated it would not have been seen by anyone else to have been given the opportunity to address it. The Administrator stated if the medication did not belong to one of the surveyors, the only other explanation would have been the pill fell out of the chair after being moved. The Administrator stated it was important to ensure medication was not on the ground for resident safety. 4. Record review of Resident #9's face sheet, dated 11/02/2023, indicated Resident #9 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included cervical disc with myelopathy (an injury to the spinal cord due to severe compression that my resulted from trauma). Record review of Resident #9's annual MDS, dated [DATE], indicated Resident #9 understood others and made herself understood. The assessment indicated Resident #9 had a BIMS score of 13, which indicated her cognition was intact. The MDS indicated Resident #9 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of Resident #9's care plan, revised on 06/17/2022 indicated Resident #9 had a memory loss, poor cognition and decreased sense of safety related to age progression and pain. The care plan intervention included, communicate with the resident/family/caregivers regarding residents' capabilities. During an observation and interview on 10/30/2023 at 9:56 a.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9's bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Resident #9 stated a family member brought those to her because her right ear was stopped up. Resident #9 stated I haven't started taking the vitamins. During an observation on 10/31/2023 at 2:37 p.m., Resident #9 was lying in bed. There was a bottle labeled equate ear drops on Resident #9 bedside table. There was a bottle labeled women's multivitamins and triple antibiotic ointment on her dresser. Record review of the physician order summary report dated 11/02/2023 did not indicate Resident #9 had an order for ear drops or triple antibiotic ointment. The physician order summary report indicated Resident #9 had an order for multivitamins with a start date 11/02/2023. During an observation on 11/01/2023 at 3:10 p.m., the DON removed the multivitamins, ear drops and triple antibiotic ointment and instructed Resident #9 that the facility needed to store the medications for safety. During an interview on 11/01/2023 at 4:22 p.m., the Director of Resident Support Services stated she conducted daily rounds for Hall 4 which included Resident #9. The Director of Resident Support Services stated she went in to check on the resident, make sure the room was clean and looked for OTC medications. The Director of Resident Support Services stated she completed rounds this week. The Director of Resident Support Services stated she did notice the ear drops, multivitamins and the triple antibiotic ointment. The Director of Resident Support Services stated she was not aware that Resident #9 could not have the medications at bedside. The Director of Resident Support Services stated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 38 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was important that medications were not at bedside because she could use too much, and it was also good for the nurses to keep track on when it was given. During an interview on 11/02/2023 at 9:11 a.m., the DON stated OTC medications were not allowed to be kept at bedside. The DON stated OTC medications were kept in the medication cart. The DON stated families were educated to bring medications to the charge nurse or herself so an order could be obtained and kept in the medication cart. The DON stated if the resident was having ear pain, the resident should have notified the charge nurse or herself so the doctor could be notified. The DON stated she monitored by daily rounds that was conducted by the department heads and nursing staff to oversee any OTC at the bedside. The DON stated it was important that medications were not left at bedside for the safety of other residents and the nursing staff would be aware of what the resident was actually taking. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated OTC medications were not allowed to be kept at bedside. The Administrator stated she expected all medications to be delivered and administered by staff if there was an order for it. The Administrator stated it was important that medications were not left at bedside, so the nursing staff was aware of what medications the residents were taking. Record review of the facility's policy Bedside Medication Storage revised in 08/2020, indicated .Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) .1. A written order for the bedside storage of medication is present in the resident's medical record Record review of the Storage of Medications policy, dated 08/2020, revealed .provider pharmacy dispenses medications in containers that meet regulatory requirements .Medications are kept in these containers .Only those lawfully authorized to administer medications are permitted to access medications .all medications dispensed by the pharmacy are stored in pharmacy container with pharmacy label .medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart . Record review of the Administration Procedures for All Medications policy, dated 08/2020, revealed .Once removed from the package or container, unused or partial doses should be disposed of in accordance with the medication destruction policy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 39 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature 1 of 1 lunch meal reviewed for palatability and temperature. Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #41, Resident #28, and Resident #19 who complained the food was served cold and did not taste good. The facility failed to ensure the Dietary Manager followed the recipe for pureeing the Swiss steak and California Blend Vegetables (the lunch menu). This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. During an interview on 10/30/2023 beginning at 9:25 AM, Resident #41 stated the food was cold and bland at times. During an interview on 10/30/2023 at 4:11 PM, Resident #28 said sometimes the food smelled like dogfood, and she could not eat it. She stated the food was cold. During an interview on 10/30/2023 at 1:07 PM, Resident #19 said the food was bland and cold. During an observation and interview on 10/31/2023 12:52 PM, the Dietary Manager and four surveyors sampled a lunch tray. The sample tray consisted of oven fried chicken, scalloped potatoes, herbed zucchini, garlic bread, and apple crisp. The Dietary Manager said thehe oven fried chicken was lukewarm. The Dietary Manager said the scalloped potatoes were bland and dry. The Dietary Manager said herbed zucchini was bland and overcooked. During an interview on 10/31/2023 at 4:32 PM, the Dietary [NAME] said he was unaware of any food complaints. The Dietary [NAME] said he ensured food was palatable and appetizing by making sure the food looked appetizing to him and by tasting each entrée. The Dietary [NAME] stated the importance of ensuring food looked appetizing and tasted well was to ensure residents wanted to eat the food. During an interview on 11/02/2023 at 01:30 PM, the Administrator said she expected dietary staff to ensure the food was appetizing and palatable. The ADM stated she had a test tray every day for lunch and supper. The Administrator said she did not have any issues with the palatability of the trays. The Administrator stated ensuring the food was palatable and appetizing was important so residents would find the food enticing. Record Review of the Food Preparation and Service Policy with a revised date of April of 2022, did not address the palatability and temperature of the food. 2. During an observation and record review on 10/30/2023 at 11:52 a.m., of the facility menu indicated that on Monday 10/30/2023 Swiss steak and gravy, California blend vegetables, macaroni and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 40 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0804 cheese, roll, and lemon bars was to be served for lunch. (Cycle: Week 1 Regular dated 10/30/2023) Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 10/30/2023 at 11:52 a.m., revealed the Dietary Manager prepared the pureed meal for the residents. The Dietary Manager had 4 beef hamburger patties in the blender. He said he had 3 residents who received pureed meals. He placed the hamburger patties into the blender and proceeded to puree. The Dietary Manager stopped the blender and added an unmeasured amount of gravy to the blended meat and continued to process. The Dietary Manager said if the food in the blender became runny, he added a small amount of thickener. The Dietary Manager took the blender and emptied the mixture into a metal pan on the steam table. The Dietary Manager said he watched the consistency of the food until it looked to be the consistency of pudding. The Dietary Manager scooped out 3 servings of the California blend vegetables with a large spoon and placed it into the blender and pureed. He then poured an unmeasured amount of thickener into the vegetables and said it was too thin of a consistency and continued to blend. The Dietary Manager then placed the mixture in a pan and placed the pan on the serving line. The Dietary Manager said he normally followed a recipe when he pureed food. The Dietary Manager said that day he did it by memory. The Dietary Manager said following the menu and recipe for all meals was important to maintain the nutrient value of the food and to maintain residents' weights. Residents Affected - Some Record review of the undated Swiss Steak/Gravy Puree Recipe revealed: Place portions needed into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with a 4 TBSP thickener and ¾ cup hot liquid (both); mix well with a wire whip. Add ½ of the slurry to the meat; process for 1 minute. If too dry, add more slurry until the meat is a pudding consistency. With a rubber spatula, scrape down sides of the bowl and reprocess 30 seconds. Reheat to 165 degrees Fahrenheit and serve meat with 1 #8 scoop topped with 1oz of gravy. Record review of the undated California Blended Vegetables Puree Recipe as follows: Remove portions needed from regular prepared recipe and place into a food processor. Process until fine; for every 5 portions needed, add 2.5 TBSP thickener; process until smooth. Scrape down the sides of the bowl with a rubber spatula; reprocess 30 seconds. Reheat to 165 degrees Fahrenheit and serve with a #12 scoop. During an interview on 10/30/2023 at 4:36 PM, the Administrator stated she expected dietary staff to follow the menu and the recipes for pureed food. The Administrator stated the importance of following the recipe was to ensure residents had the appropriate nutrients. Record review of the Food Preparation and Service Policy with a revised date of April of 2022, revealed the policy did not address following pureed recipes or preparing pureed meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 41 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care for 2 of 2 meals (Lunch on 10/30/2023 AND 10/31/2023) observed for frequency of meals. The facility failed to serve the 10/30/2023 and 10/31/2023 lunch meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life. The findings include: Record review of the facility's mealtimes indicated breakfast at 7:15 AM, Lunch at 12:00 PM, and Supper 5:15 PM. During an observation on 10/30/2023 at 12:42 PM, revealed the residents in the dining room were served lunch. During an observation on 10/31/2023 at 12:48 PM, revealed the residents on 600 hall were served lunch. During an interview on 10/31/2023 at 12:42 PM, Resident #42 said lunch should be served by 12:00 noon and he had not received his tray yet. Resident #42 said this happened all the time. During an interview on 10/31/2023 at 04:32 PM., the Dietary Manager said he was not aware the meals were not served timely or being served cold. The Dietary Manager said the dining hall was served around noon. The Dietary Manager said it was important for the meals to be served on time to the residents, so the meals were hot and tasted good, and the residents meet their nutritional requirements. During an interview on 11/02/2023 at 1:30 PM., the Administrator said that she expected the Dietary Manager to ensure the food to be palatable and served as scheduled to prevent resident weight loss. Record review of the Food Preparation and Service Policy with a revised date of April of 2022, revealed the policy did not address scheduled meal times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 42 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 service in the facility's only kitchen Residents Affected - Many The facility failed to ensure that kitchen staff appropriately restrained their hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: 1. During an observation on 10/30/2023 starting at 09:03 AM revealed: two dented cans of Campbell's Cream of Mushroom Soup in the kitchen pantry. the [NAME] was not wearing the hairnet appropriately to restrain the sides and back of hair. the Dishwasher was not wearing the hairnet appropriately to contain facial hair, approximately one half inch mustache. During an observation on 10/30/2023 at 09:11 AM, revealed the dishwasher was in the kitchen without a hairnet on appropriately. The dishwasher was not wearing a hair net to contain facial hair approximately one half inch mustache. During an observation on 10/30/2023 at 09:30 AM., revealed the [NAME] was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an observation on 10/31/2023 at 09:30 AM, revealed the [NAME] was in the kitchen without a hairnet on appropriately. The Cook's hair was sticking out the sides and the back of the hairnet. During an interview on 10/30/2023 at 02:00 PM., the [NAME] said the hairnet should be worn appropriately by tucking all the hair inside the hairnet to prevent any type of cross contamination. During an attempted telephone interview on 10/31/2023 at 11:30 AM., the Dishwasher did not answer the phone. During an attempted telephone interview on 10/01/2023 at 02:30 PM., the Dishwasher did not answer the phone. During an interview on 10/31/2023 at 04:32 PM., the Dietary Manager said the damaged food cans should be separated from cans of food to be served. The Dietary Manager said all staff should wear hairnets that covered their hair appropriately while in the kitchen. The Dietary Manager said those items or important to keep the residents healthy and prevent cross contamination and food borne illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 43 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/02/2023 at 1:30 PM., the Administrator said that she expected the Dietary Manager to check behind the staff to ensure that the tasks to prevent infection and cross contamination and food borne illness were completed. Record Review of the Food Preparation and Service Policy with a revised date of April of 2022, indicated . all food purchased will be wholesome, manufactured, processed, and prepared in compliance with all state, federal and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food born illness. 1. Food is delivered at the appropriate temperature and inspected prior to storage for signs of contamination. D. No dented cans. 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. 11. Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded.19. Safe food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling and reheating Event ID: Facility ID: 455944 If continuation sheet Page 44 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 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 1 of 2 residents (Resident #28) and 4 of 4 staff (CNA G, CNA H, Community Cleanliness Provider O and Clinical Reimbursement Coordinator) reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure CNA G and CNA H changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure CNA G and CNA H did not touch the multi-use wipes container with their dirty gloves. 2. The facility failed to ensure the Clinical Reimbursement Coordinator sanitized her hands between each resident meal tray while passing meal trays on Hall 1. 3. The facility did not ensure Community Cleanliness Provider O kept the personal linen cart covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation starting on 10/30/2023 at 2:58 PM, CNA G and CNA H provided incontinent care to Resident #28. CNA H wiped Resident #28's front perineal area using different wipes, and when she was removing the wipes from the wipe container, she was touching the container with her dirty gloves. Resident #28 was then turned onto her side. CNA G wiped Resident #28's back perineal area, and when she was removing the wipes from the wipes container CNA G was touching the wipes container with her dirty gloves. Then with her dirty gloves CNA G grabbed the clean brief, opened it up and laid it down. CNA G did not change gloves or perform hand hygiene prior to grabbing the clean brief. CNA G then changed her gloves and applied clean ones. CNA G did not perform hand hygiene after removing her dirty gloves. CNA G then placed the clean brief under Resident #28 with the dirty brief still under Resident #28. The clean brief touched the dirty brief. Resident #28 was then turned to the opposite side and CNA H removed the dirty brief, and using the same gloves applied the clean brief. CNA H did not change gloves or perform hand hygiene after removing the dirty brief. CNA G and CNA H then removed their gloves and applied new ones. CNA G and CNA H did not perform hand hygiene after removing their dirty gloves. CNA G placed Resident #28's multi-use wipe container on top of her snacks on the over bed table. CNA H and CNA G removed their gloves. CNA H took the trash outside of the room and washed her hands down the hall. CNA G did not perform hand hygiene. During an interview on 10/30/2023 at 3:08 PM, CNA G said she should change gloves when going from front to back. CNA G said she should have performed hand hygiene in between glove changes, but she forgot her gel hand sanitizer. CNA G said she should not have touched the wipes container with her dirty gloves. CNA G said she touched the wipes container with her dirty gloves because she was not paying attention. CNA G said she should not touch the wipes container with dirty gloves because it could result in the spread of infection. CNA G said she should not have touched the clean brief with her dirty gloves. CNA G said they should have removed the dirty brief and then applied the clean brief. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 45 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 CNA G said the clean brief should not touch the dirty brief because they did not want the germs getting on the clean brief. CNA G said not performing proper incontinent care placed the residents at risk for getting an infection. CNA G said she had a training on incontinent care about 2 months ago. During an interview on 10/30/2023 at 3:18 PM, CNA H said she should have washed her hands in between glove changes. CNA H said she forgot to bring her hand sanitizer with her, and she did not know why she didn't go into the resident's bathroom and wash her hands. CNA H said she should have changed gloves before putting on the clean diaper. CNA H said she should not touch the wipes container with dirty gloves. CNA H said it was important for proper incontinent care to be performed for cleanliness and for infection. CNA H said it was important to perform hand hygiene for infection control. CNA H said she had training on incontinent care and hand hygiene every 3 months. During an interview on 11/02/2023 at 12:38 PM, the DON said when doing incontinent care, the CNAs should pull wipes prior to beginning incontinent care, and if they needed more wipes, they should remove their gloves perform hand hygiene and get more. The DON said the CNAs should not touch the wipes container with dirty gloves. The DON said hand hygiene should be performed before the start of care, at the end of care, and in between glove changes. The DON said gloves should be changed when moving from dirty to clean. The DON said the clean brief should not be touched with dirty gloves. The DON said the dirty brief and the clean brief should not touch each other. The DON said incontinent care was monitored by check offs performed quarterly by the ADON and herself. The DON said she also performed random walk ins and watched the CNAs provide incontinent care. The DON said during her observations she had noticed some problems including hand hygiene and bagging items appropriately. The DON said she could not recall any issues with CNA G and CNA H. The DON said it was important to perform hand hygiene and proper incontinent care for infection control and to prevent skin breakdown and infections. During an interview on 11/02/2023 at 1:41 PM, the Administrator said the nursing staff was responsible for ensuring incontinent care was provided to the residents properly. The Administrator said she expected for incontinent care to be done properly and for the staff to perform adequate hand hygiene. The Administrator said it was important for proper incontinent care to be performed and hand hygiene done for infection control. During an interview on 11/02/2023 at 2:03 PM, the Infection Control Preventionist said gloves should be changed when going from dirty to clean. The Infection Control Preventionist said hand hygiene should be performed in between glove changes and before and after providing care. The Infection Control Preventionist said wipes should be removed from the container prior to beginning incontinent care, and the wipes container should not be touched with dirty gloves. The Infection Control Preventionist said the dirty brief should not touch the clean brief. The Infection Control Preventionist said she monitored incontinent care by performing competency check offs and random pop ins. The Infection Control Preventionist said she was responsible for ensuring the CNAs were performing proper incontinent care. The Infection Control Preventionist said it was important for proper incontinent care to be performed to decrease the risk of infections. The Infection Control Preventionist said it was important to perform hand hygiene to decrease the spread of infection. 2. During an observation on 10/30/23 between 12:26 PM and 12:34 PM, the Clinical Reimbursement Coordinator took a meal tray from the meal cart and went into a room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #5's meal tray, then left the room and did not sanitize her hands. The Clinical Reimbursement Coordinator took another meal tray from the meal cart and went into another room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #31's meal tray, then left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 46 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 room and applied hand sanitizer. The Clinical Reimbursement Coordinator took another meal tray from the meal cart and went into another room on Hall 1. The Clinical Reimbursement Coordinator set up Resident #25's meal tray, then left the room and did not sanitize her hands. During an interview on 11/02/23 beginning at 9:08 AM, the Clinical Reimbursement Coordinator stated she should have performed hand hygiene while passing meal trays between each resident. The Clinical Reimbursement Coordinator stated she believed she had performed hand hygiene. The Clinical Reimbursement Coordinator stated it was important to perform hand hygiene between each meal tray for infection control. During an interview on 11/02/23 beginning at 10:41 AM, the DON stated she expected staff to make sure hands were sanitized between each resident while passing meal trays. The DON stated hand hygiene was monitored by random observations. The DON stated it was important to ensure hand hygiene was performed between each resident while passing meal trays for infection control. The policy for passing meal trays was requested and not provided upon exit. The DON stated corporate staff explained there was no policy for passing meal trays. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated she expected staff to sanitize their hands between each resident while passing meal trays. The Administrator everyone was responsible for monitoring to ensure hand hygiene was performed. The Administrator stated it was important to ensure hand hygiene was performed for infection control. Record review of the facility's policy titled, Perineal Care, effective 10/01/21, indicated, To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Put on gloves. 7. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. 8. For a female resident: a. Use wipes and apply skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back . (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. 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 or labia . Change wipe and apply skin cleansing agent. d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. 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 labia . 10. Discard disposable items into designated containers. 11. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean the bedside stand. 15. Wash and dry your hands thoroughly . 3. During an observation and interview on 10/30/2023 at 11:46 a.m., Community Cleanliness Provider O was pushing the personal linen cart, uncovered, on Hall 6. Community Cleanliness Provider O stated she did not know if the linen cart should be covered. Community Cleanliness Provider O stated she would go speak with her supervisor to see if the linen cart should be covered and get back with the surveyor. During an interview on 10/30/2023 at 11:51 a.m., Community Cleanliness Provider O stated the linen cart should be covered while transporting and when not being used. Community Cleanliness Provider O (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 47 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 stated it was important to ensure the cart was covered to prevent germs contaminating the linens. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's untitled in service dated 09/12/2023 indicated no documented evidence Community Cleanliness Provider O was in-service about ensuring the laundry was covered when brought into the building. Residents Affected - Some During an interview on 11/01/2023 at 11:30 a.m., the Laundry Supervisor stated the linen cart should be covered at all times unless staff were taking out items. The Laundry Supervisor stated he had in-serviced his staff verbally and written about ensuring the cart was covered when they brought it into the building. The Laundry Supervisor stated he was responsible for monitoring and overseeing by daily morning meetings and random spot checks. The Laundry Supervisor stated when an issue was noted, staff was in serviced immediately. The Laundry Supervisor stated it was important to ensure the cart was covered to prevent contamination. During an interview on 11/02/2023 at 9:11 a.m., the DON stated the linen cart was to be covered while not being occupied. The DON stated the housekeeping supervisor was responsible for monitoring to ensure that staff was making sure that the cart was staying covered at all times while transporting. The DON stated it was important to ensure the cart was covered while transporting to prevent a risk of possible infection control issues. During an interview on 11/02/2023 at 11:19 a.m., the Administrator stated the linen cart should be covered while transporting residents belonging. The Administrator stated she monitored by doing random hall rounds and in-servicing staff when an issue was noted. The Administrator stated she had not noticed any issues. The Administrator stated it was important to keep the cart covered to ensure the laundry stays clean. Record review of the facility's policy titled Laundry and Linen processing, dated 10/24/2022, indicated The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 48 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 3 of 3 residents (Residents #13, #36, and #44) reviewed for antibiotic use. Residents Affected - Some The facility failed to ensure Residents #13, #36, and #44 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #13's face sheet, dated 11/01/2023, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Quadriplegia (paralysis of all 4 limbs), Muscle Wasting, Schizoaffective Disorder (abnormal thought process and unstable mood), Chronic Viral Hepatitis C (viral infection that causes liver swelling resulting in liver damage), Type 2 Diabetes Mellitus without complications (a chronic condition that affects how the body processes blood sugars), Bipolar (a mental disorder characterized by periods of depression and periods of abnormal elevated mood), Chronic Obstructive Pulmonary (a group of lung diseases that block airflow and make it difficult to breath), Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances on the artery walls), Unspecified Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Neurogenic Bladder (lack of bladder control related to brain, spinal cord or nerve problem), Gout (inflammatory arthritis - red swollen joint), Gastro-Esophageal Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of the MDS Resident Assessment Screening dated 09/18/2023 indicated Resident #13 was able to make self-understood and understood others. The MDS assessment indicated Resident #13 had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS assessment Indicated Resident #13 required extensive assistance with two-person assistance for bed mobility, transfers (Hoyer lift), toilet use, dressing and personal hygiene. Record review of a care plan last revised on 07/07/2023 revealed Resident #13 had impaired immunity related to history of UTI. Record review of Resident #13's Order Summary Report dated 11/08/2023 revealed Cipro 500 mg, take 1 tablet by mouth every 12 hours for UTI for 7 days with a start date of 10/27/2023. Record review of the Resident #13 MAR for October of 2023 indicated Cipro 500 mg, take 1 tablet by mouth every 12 hours was administered as ordered from 10-27-2023 thru 11-02-2023. Record review of Resident #13's McGeers Criteria for Infection effective date of 10/31/2023 indicated Resident #13 did not meet criteria for Cipro and the physician was notified on 10/31/2023. Record review of Resident #13 Nurses Notes dated 10/23/2023 indicated urine was dark in color and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 49 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 resident with poor intake. Level of Harm - Minimal harm or potential for actual harm Record review of Resident#13's Electronic Health Record indicated no UA or culture was completed. Residents Affected - Some 2. Record review of Resident #44's face sheet, dated 11/01/2023 revealed a [AGE] year old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Base of Neck of Left Femur, Rheumatoid Arthritis (a chronic inflammatory disorder affecting many joints), Type 2 Diabetes Mellitus (a chronic condition that affects how the body processes blood sugar), Unspecified Sequelae of Cerebral Infarction(occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breath), Unspecified Abnormalities of Gait and Mobility, Repeated Falls, Pain, Alzheimer's Disease ( a progressive disease that destroys memory and other important mental functions). Record review of the MDS Resident Assessment and Care Screening dated 09/22/2023 indicated Resident #44 was able to make self-understood and understood others. The MDS assessment indicated Resident #44 had a BIMS score of 13, which indicated cognitively intact. The MDS assessment Indicated Resident #44 required extensive assistance for bed mobility, transfers, toilet use, dressing and personal hygiene. Record review of Resident #44's Order Summary Report dated 11/08/2023 revealed Macrobid 100 mg take 1 tablet by mouth two times a day for UTI for 7 days with a start date of 10/12//2023. Record review of the Resident #44's MAR for October of 2023 indicated Macrobid 100 mg take 1 tablet by mouth two times a day was administered from 10/12/2023 thru 10/15/2023. Record review of Resident #44's McGeers Criteria for Infection effective date of 10/12//2023 indicated Resident #44 did not meet criteria for Macrobid and the physician was notified on 10/12/2023. Record review of Resident #44's Nurses Notes dated 10/06/2023 signed by the ADON indicated in and out catheter done due to increased confusion with cloudy yellow urine collected and sent to lab for UA and C&S. Record review of Resident #44's Nurses Notes dated 10/12/2023 signed by the ADON indicated in and out catheter done due to increased confusion with cloudy yellow urine collected and sent to lab for UA and C&S. Record review of Resident #44's urine culture indicated bacteria was present in the urine. 3. Record review of Resident #36's face sheet dated 11/01/2023 revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Base of Neck of Left Femur, Unspecified fall, Age-Related Osteoporosis (bones become weak and brittle), Chronic Diastolic Congestive Heart Failure (a condition in which the heart's main pumping chamber becomes stiff and unable to fill properly), Rheumatoid Arthritis (a chronic inflammatory disorder affecting many joints), Muscle Weakness, Abnormalities of Gait and Mobility, Cognitive Communication Deficit. Record review of the MDS Resident Assessment and Care Screening dated 08/23/2023 indicated Resident #36 was able to sometimes make self-understood and understood others. The MDS assessment indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 50 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 Resident #36 had a BIMS score of 02, which indicated severely cognitively impaired. The MDS assessment Indicated Resident #36 required limited assistance for bed mobility, and extensive assistance with transfers, toilet use, dressing and personal hygiene. Record review of Resident #36's Order Summary Report dated 11/08/2023 revealed Macrobid 100 mg take 1 tablet by mouth two times a day for UTI for 7 days with a start date of 10/25/2023. Record review of the Resident #36's MAR for October of 2023 indicated Macrobid 100 mg take 1 tablet by mouth two times a day was administered from 10/25/2023 thru 10/31/2023 per orders. Record review of Resident #36's McGeers' Criteria for Infection effective date of 10/31//2023 indicated it had not been completed. Record review of Resident #36's Nurses Notes dated 10/21/2023 signed by the DON indicated resident complained of burning with urination. Physician was notified and new order received for UA collection. Record review of Resident #36's Nurses Notes dated 10/25/2023 signed by the DON indicated UA C&S positive for E. Coli and new order received from physician to start Macrobid. During an interview on 11/01/2023 at 01:08 PM, the ADON said the antibiotic stewardship process included reviewing antibiotic orders, ensuring appropriate diagnoses and lab work to support usage was present, and the McGeer criteria (are used for retrospectively counting true infections. To meet the criteria for definitive infection, more diagnostic information (e.g., positive laboratory tests) is often necessary) was being followed. She said antibiotic should be prescribed to treat the right organism growing. The ADON said the Infection Control Preventionist was responsible for Antibiotic Stewardship, which was currently her. She said if Antibiotic Stewardship was not implemented, wrong antibiotics were ordered, and infection was not treated. The ADON said inappropriate antibiotic usage could cause resident to become resistant to antibiotic and harder to treat infections. Record review of a facility Antibiotic Stewardship policy last revised on 10/01/2022 indicated .antibiotics will be prescribed and administered to residents under guidance of the facility's antibiotic stewardship program .if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following .duration of treatment .indication of use .when a nurse calls a physician/prescriber to communicate a suspected infection .following information available . signs and symptoms .infection type .when a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber .to determine if antibiotic should be started, continued, modified or discontinued . It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use Assess residents for any infection using . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 51 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0926 Have policies on smoking. 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 follow their own established smoking policy for the facility's only smoking area and 1 of 12 residents (Resident #52) reviewed for smoking policies. Residents Affected - Some 1. The facility did not ensure Resident #52 smoked in the designated smoking area with appropriate supervision. 2. The facility did not ensure cigarette butts were disposed of in metal containers in the smoking area. 3. The facility did not ensure plastic trash was placed in the appropriate trash containers in the smoking area. These failures could place residents at risk of an unsafe smoking environment. The findings included: Record review of the face sheet, dated 10/31/23, revealed Resident #52 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of sepsis, unspecified organism (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), COPD (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and mild cognitive impairment of uncertain or unknown etiology (characterized by problems with language, memory and thinking). Record review of the MDS assessment, dated 10/10/23, revealed Resident #52 had clear speech and was understood by staff. The MDS revealed Resident #52 was able to understand others. The MDS revealed Resident #52 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #52 had no behaviors or refusal of care. The MDS revealed Resident #52 currently used tobacco. Record review of the comprehensive care plan, initiated on 05/18/23, revealed Resident #52 smoked. The goals included: Resident will have supervised smoking privileges to minimize safety risks. The interventions included: Resident will smoke only in designated smoking area with access to appropriate smoking receptacles. Record review of Resident #52's Safe Smoking Assessment, dated 07/30/23, revealed The resident requires direct supervision while smoking. During an observation on 10/31/23 beginning at 3:01 PM, multiple residents were outside in the designated smoking area. The Social Worker was supervising the smoke break and was sitting in a metal chair in the designated smoking area. Resident #52 was sitting up in her wheelchair, outside the designated smoking area on the sidewalk near a grassy area and was approximately 20 feet from a large propane tank. Resident #52 was observed smoking a red-tipped cigarette and flicking her ashes on the ground. The propane tank was in the grass with a metal chain-link fence around it. There was a large sign that read PROPANE: No Smoking; No Open Flames. There were approximately 11 red-tipped cigarette butts in the grass where Resident #52 was sitting. There were also 8 red-tipped cigarettes located in the designated smoking area. There was empty candy paper located in one of the table-top ashtrays (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 52 of 53 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 455944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Clarksville 2407 West Main Street Clarksville, TX 75426 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some located on the tables. There were several pieces of plastic trash located in the red trash can, which was filled to the very top with cigarette butts and trash. During an observation and interview on 10/31/23 at 3:38 PM, the Administrator accompanied the surveyor into the smoking area. There were approximately 11 red-tipped cigarette butts in the grass approximately 20 feet away from the propane tank. The Administrator stated Resident #52 should not have been smoking outside the designated smoking area. The Administrator stated cigarette butts should not have been thrown on the ground or in the grass. The Administrator stated she would provide in-service education to the facility staff. During an interview on 10/31/23 beginning at 4:23 PM, the Social Worker stated she was responsible for supervising residents during the 3:00 PM smoke break. The Social Worker stated Resident #52 usually sat outside the designated smoking area because she wanted to sit in the sun, but she stated Resident #52 did not normally smoke. The Social Worker stated she had not noticed Resident #52 smoking outside the designated area during the 3:00 PM smoke break. The Social Worker stated an explosion or fire could have happened if residents smoked outside the designated smoking area and threw their cigarette butts on the ground. During an interview on 11/01/23 beginning at 4:43 PM, the Director of Environmental Services stated he was responsible for ensuring the smoking area was kept clean. The Director of Environmental Services stated he cleaned the smoking area at least three times a week. The Director of Environmental Services stated there should not have been trash in the red trash can, which was for cigarette butts only. He stated there also should not have been cigarette butts on the ground or in the grass or trash in the ashtrays. The Director of Environmental Services stated he usually emptied the red trashcan, but it had not been emptied in a week or two. The Director of Environmental Services stated it was important to ensure the smoking area was free of hazards to make the facility look better and prevent the potential for fires. During an interview on 11/02/23 beginning at 11:39 AM, the Administrator stated the Director of Environmental Services was responsible for ensuring the smoking area was kept clean and free of hazards. The Administrator stated it was important to keep the smoking area clean and free of hazards for fire prevention. Record review of the Smoking policy, undated, revealed It is the policy of this community to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. The policy further revealed Smoking by residents is allowed outside in designated, marked smoking areas . and IDT will develop an individualized plan for .required supervision for residents who smoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 53 of 53