Inspection·October 5, 2024

F 0600 Level of Harm - Actual harm Residents Affected - Few indicated Resident #1 voiced no recollection of being with the male Resident #2 and exhibited no emotional distress. The plan was to continue to provide psychotherapy focused on reducing symptoms of depression, increasing overall sense of well-being, and self-care. 2. Record review of Resident #2's face sheet dated 10/04/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behaviors), high blood pressure, psychotic disorder (mental disorder characterized by a disconnection from reality), dementia (loss of cognitive functioning), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #2's quarterly MDS dated [DATE] indicated he had a BIMS score of 8 which means he had moderate cognitive impairment. The MDS also indicated he required supervision for bathing, and he was independent with eating, transverse, and bed. mobility The MDS did not indicate that he had any behaviors. Record review of Resident #2's care plan revised 10/4/2024 after the sexual incident, indicated he had a potential to have behaviors related to dementia, poor impulse control, and schizophrenia hallucinations. The care plan included interventions of 1 on 1 monitoring for sexual behaviors and psychiatric/psychogeriatric consult as indicated. The care plan did not include any behaviors prior to 10/4/2024. Record review of the Provider Investigation Report dated 10/04/24 at 7:00 AM, indicated a search found Resident #1 laying across the bed in Resident #2's room with her pants and brief down and her shirt pulled up. Resident #2 was next to her fully clothed leaned over Resident #1 with his mouth on Resident #1's breast. He stopped when the LVN A walked in. His affect was no different than his usual. Resident #1 was tearful. She was assisted to dress and come out of the room. The report indicated a head-to-toe assessment was completed with no skin issues, no redness, bruising, or pain noted to the perineal area. A psychological assessment was to be completed by the Facility Counseling MD on 10/5/2024 for Resident #1 and Resident #2. The report also noted that Resident #2 would be placed on 1 on 1 supervision. Record review of the visit note from the Facility Counseling MD dated 10/5/2024 at 12:15 PM indicated Resident #2 shared no recollection of the sexual event but said I must have been inappropriate and offered no other details. Resident #2 presented with a calm demeanor and exhibited no emotional distress. The plan was to continue to provide psychotherapy focused on reducing symptoms of depression, increasing overall sense of well-being, and self-care. Record review of the facility in-service dated 10/5/2024 indicated the staff were educated over dementia care and sexuality. Record review of the facility in-service dated 10/5/2024 indicated the staff were educated over abuse and neglect. Record review of the facility 15-minute activity checks dated 10/4/2024 - 10/5/2024 indicated there had continuously been a staff member 1 on 1 with the Resident #2. During an observation and interview on 10/05/24 at 11:30 AM, CNA C was sitting outside of Resident #2's room and said she was on 1 on 1 duty for observation of Resident #2. CNA C said she had been on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 2 of 4 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 10/05/2024 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 0600 Level of Harm - Actual harm duty 10/04/24 for the 2:00PM-10:00 PM shift and returned on 10/05/24 at 6:00 AM and she had relieved another CNA who worked from 10/04/24 at 10:00PM until 10/05/24 at 6:00 AM. She said Resident #2 had not had any sexual behaviors and she had never known him to have any. CNA C said she was notified of the incident but had not had an abuse and neglect in-service since the incident. Residents Affected - Few During an observation and interview on 10/05/24 at 11:40 AM, Resident #2 was laying in his bed and said he did not recall a woman in his bed on yesterday 10/04/24, nor did he recall any incident. He said he thought he slept through breakfast 10/04/24. Resident #2 said he did not have any close friends, but he tried to be nice to everyone. During an observation and interview on 10/05/24 at 12:00 PM, Resident #1 was sitting in front of the nurse's station in her wheelchair. She was in a pleasant mood and denied anyone hurting her or touching her inappropriately. During an interview on 10/05/24 at 12:30 PM, the Facility Counseling MD said she had been seeing Resident #2 for 1-2 months. She said he had continued to get adjusted to nursing facility but had never spoken of any type of relationship at the facility. She said he had kept to himself. The Facility Counseling MD said Resident #2 was always alert and oriented to person and place but on 10/05/24 he was not and was very forgetful. He told her he must had been inappropriate but did not indicate what was done. During an interview on 10/05/24 at 1:00 PM, LVN A said on 10/04/24 at about 6:45 AM Resident #1 was sitting at the nurse's station and Resident #2 was sitting in the front lobby. She said 15 minutes later the staff were looking for Resident #1 to go to breakfast and she was not at the nurse's station. LVN A said she went down hall 400 while other staff searched other hallways and she found Resident #1 in the room of Resident #2 laying across the middle of his bed with her pants and brief at her knees and her shirt was up to her chin. She said Resident #2 had his mouth on Resident #1's breast and he was fully clothed. She said Resident #1 had her hands cupped over her perineal area. LVN A said once she knocked Resident #2 sat upright. LVN A said she asked Resident #1 if she was ok, and she shook her head no. She said when she asked Resident #1 if he touched her, she said yes and when she asked if Resident #2 did anything else she said no. LVN A said she assisted Resident #1 to put clothes on and removed her from Resident #2's room and placed Resident #2 on 1 to 1 observation. She said she notified the Administrator, the DON, Resident #1's son, and the doctor of the incident. During an observation and interview on 10/05/2024 at 1:30 PM Resident #2 was sitting in the front lobby with CNA C sitting with him. CNA C said he had no behaviors noted. During an interview on 10/05/24 at 4:11 PM, Resident #2 said he had short term memory problems, but he did now remember Resident #1 coming to his room. He said that was the first time she came in there. He said he assisted Resident #1 onto his bed because he did not have a chair in his room. Resident #2 said he had been friends with her, and he thought it was a mutual thing. He said to his recollection she did not tell him no or stop. He then said he had short term memory problems and did not remember anything else about the incident. During an interview on 10/05/24 at 4:23 PM, the DON said her expectation was for the incident of suspected sexual abuse to be immediately reported to the administrator, as it was, and she then followed up with her. The DON said when there was a resident in harms ways she would step in and ensure the residents were safe. She said CNAs were immediately placed on 1 on 1 with Resident #2 to ensure he did not get to do the sexual behavior again. The DON said that all staff were responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 3 of 4 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 10/05/2024 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 0600 ensuring abuse was prevented but the administrator was the abuse coordinator. The failure of not preventing abuse placed residents at risk for trauma, pain, and emotional problems. Level of Harm - Actual harm Residents Affected - Few During an interview on 10/05/24 at 4:30 PM, the Administrator said her expectation was for staff to report things right away and they did. She said all the staff were responsible for ensuring that no resident was subject to abuse and neglect. She said the failure placed a risk for emotional trauma and physical trauma. Record review of the facility's policy titled Abuse effective 02/01/2017 and last revised 01/01/23 indicated: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving residents, family members, or legal guardians, care taker, friends, or other individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455944 If continuation sheet Page 4 of 4